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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881341
Report Date: 04/22/2026
Date Signed: 04/22/2026 01:00:10 PM

Document Has Been Signed on 04/22/2026 01:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KELLY'S SUNSET VILLAFACILITY NUMBER:
371881341
ADMINISTRATOR/
DIRECTOR:		WELKER, KELLY DFACILITY TYPE:
740
ADDRESS:1205 SUNSET HEIGHTS ROADTELEPHONE:
(619) 504-5049
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 5DATE:
04/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Garrett Welker, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 4/22/26, Licensing Program Analyst (LPA) Kyle Wellington arrived unannounced to conduct an annual inspection. LPA was greeted and let into the facility by Caregiver, Cristina Agoscruz, who was informed of the purpose of the visit. Administrator (Admin), Garrett Welker, arrived shortly thereafter to the facility to meet with LPA. LPA observed two (2) staff and four (4) residents present at the facility. The census at the facility is five (5) residents with one (1) resident in the hospital. Two (2) residents are receiving hospice care.

LPA received a staff and resident roster from the Caregiver. LPA toured the inside and outside of the facility with the Caregiver. LPA conducted an observation and record reviews for the inspection.

Facility Overview: The facility is a one story house with six (6) resident bedrooms, one (1) staff room, two (2) resident bathrooms, one (1) staff bathroom, kitchen, dining room, family room, laundry room and attached garage. There were no pools, bodies of water or firearms at the facility. Facility has a fire clearance to serve six (6) non-ambulatory elderly residents of which one (1) may be bedridden. Facility has an approved hospice waiver for six (6) residents.

Infection Control: LPA observed hand soap dispensers and hand sanitizers throughout the facility. Cleaning equipment and cleaning supplies were kept locked in the garage and available for regular facility maintenance. LPA reviewed the facility’s infection control plan which met the department’s requirements.

Physical Plant: LPA observed the inside and outside of the facility to be clean, safe and well kept. The floors, windows and doors were clean and well maintained. The family room and dining room furniture was
NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Kyle Wellington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KELLY'S SUNSET VILLA
FACILITY NUMBER: 371881341
VISIT DATE: 04/22/2026
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in good repair. The halls had night lights and no obstructions. The residents’ bedrooms were neat, organized and had the required bedding, furniture and lighting. Bathrooms were clean, tidy and contained soap, paper towels, grab bars and non-slip tile in the showers. The hot water temperature in the bathroom was measured at 108.2 F. Clean linens and towels were readily available in a cabinet in the hall. Laundry equipment appeared to be in good working condition. Laundry supplies were kept in a cabinet in the locked laundry room. Incontinent supplies and cleaning supplies were stored separate from the emergency food and water in the locked garage. The one (1) fire extinguisher was charged and available for use. LPA and Admin tested one (1) of the smoke and carbon monoxide detectors and found it to be operational and hard wired. Facility had a pull system fire alarm in the hall. The backyard was clean, free of hazards and contained outdoor furniture and shaded areas for the residents.

Kitchen/Food Service: LPA observed the kitchen to be clean, organized, and well maintained. The kitchen had the ability to prepare and store food in a safe and clean environment. Kitchen appliances appeared to be in good working condition. All sharp and dangerous objects were kept in a locked drawer in the kitchen inaccessible to residents. Cleaning supplies were kept in a locked cabinet under the sink inaccessible to residents. The refrigerator/freezer was clean, stocked and at the required temperatures. Food in the refrigerator/freezer and cabinets was properly stores and not expired. The facility has at least a two day supply of perishable foods and a seven day supply of non perishable foods. The hot water temperature in the kitchen was measured at 110.4 F.

Care & Supervision: LPA observed the facility had sufficient staff present to supervise the residents.

Administration: LPA observed that the facility's license, Long Term Care Ombudsman information, residents' personal rights information and complaint information was posted in the hall near the front door. Liability insurance was up to date. Admin holds a current Administrator Certificate and CPR Certification. Admin has a criminal record clearance.

Record Review and Resident/Staff Files: LPA compared the staff present at the facility and on the staff roster to the Guardian staff roster for criminal record clearance. LPA reviewed the records of two (2) staff files and three (3) residents’ files. The files contained all the required documentation and paperwork. The staff and residents’ files were kept in a locked closet in the kitchen inaccessible to unauthorized individuals.
NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Kyle Wellington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KELLY'S SUNSET VILLA
FACILITY NUMBER: 371881341
VISIT DATE: 04/22/2026
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Health Related Services/Incidental Medical Services: LPA observed all residents’ medications were kept in a locked in a cabinet in the kitchen inaccessible to residents. LPA reviewed two (2) residents' medication to the facility’s medication log to make sure all medication was accounted for and dispensed correctly. First Aid kit contained all the required items and was kept in a locked closet in the kitchen inaccessible to residents.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan. The plan was current and up to date. Safety and fire drills have been conducted. All facility exits were clear of obstructions.

No deficiencies were cited during this visit.

Exit interview was conducted with the Administrator and a copy of this report was given to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Kyle Wellington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC809 (FAS) - (06/04)
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