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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881394
Report Date: 02/22/2023
Date Signed: 02/22/2023 11:35:56 AM

Document Has Been Signed on 02/22/2023 11:35 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DOLORE HOMEFACILITY NUMBER:
371881394
ADMINISTRATOR:DAO, LUONGFACILITY TYPE:
740
ADDRESS:1412 DOLORE PLACETELEPHONE:
(619) 717-1574
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 0DATE:
02/22/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:ADMINISTRATOR, LUONG DAOTIME COMPLETED:
11:48 AM
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On February 22, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived for a scheduled visit for the purpose of conducting a pre-licensing inspection. LPA Mixson met with Administrator introduced self and toured the facility inside and outside.
The location is a single story home with six bedrooms, two bathrooms, a living room, dinning room, family room, kitchen, and two car garage with backyard, front yard, and side yard. On 01/23/2023, The City of Escondido Fire Department Administration & Prevention approved this location for zero ambulatory, five non-ambulatory, and one bedridden residents.
LPA Mixson observed where medications will be stored, locked, and inaccessible to residents. The home is equipped with lights in the passages, and stocked with emergency night lights throughout. The smoke and carbon monoxide detectors were tested and are operable. LPA Mixson observed the fire extinguisher it is charged and in the green. LPA Mixson observed cleaning supplies to be locked and inaccessible. The water temperature was tested and within regulation requirements.
The sharp objects are locked in a kitchen drawer, plenty of pots, pans and other kitchen accessories. The kitchen is stocked with the required amounts of non-perishable and perishable food items. All doors, and passageways are clear from obstruction. There were no bodies of water on the premises. LPA Mixson observed beds have the required linen and supplies. There was enough clean linen and hygiene items. There was appropriate lighting in each room with night stand, dresser and chair.
LPA Mixson observed central heating and air conditioning systems. The Administrator dialed the land line phone number (760) 294-9804 and it was operable. Outside/Yards: No obstructions observed. No weapons or ammunition on the property.
An exit interview was conducted, a copy of this report was provided to Administrator. Component III reviewed.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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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