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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881506
Report Date: 02/19/2025
Date Signed: 02/19/2025 01:38:37 PM

Document Has Been Signed on 02/19/2025 01:38 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:CHAMPINE MANORFACILITY NUMBER:
371881506
ADMINISTRATOR/
DIRECTOR:		AUSTRIA, VIRNA LIZA R.FACILITY TYPE:
740
ADDRESS:1725 TOBACCO ROADTELEPHONE:
(858) 705-9696
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 4DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Administrator, Virna AustriaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 2/19/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator, Virna Austria who was informed of the purpose of the visit. The facility has a fire clearance to serve two (2) non-ambulatory and four (4) ambulatory elderly residents. The facility was granted a hospice waiver for three (3) residents and LPA was informed none of the facility's current residents are receiving hospice services.

LPA toured the facility with Administrator Austria and observed the facility is made up of a two-story home with six (6) resident bedrooms, two (2) resident bathrooms, a kitchen, dining room and living room. Resident bedrooms had the required bedding, furniture, and lighting. Bathrooms had grab bars and non-skid mats in the showers. No bodies of water were observed on the premises. Indoor and outdoor passageways were free of obstruction. The facility has more than two-day supply of perishable foods and seven-day supply of non-perishable foods, which are stored in a safe and healthful manner. Medications are secured in a locked medication cart near the dining room. Administrator Austria tested one of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed charged fire extinguishers mounted throughout the facility last serviced on 4/18/2024. The facility's certificate of liability insurance expires on 3/12/2025. Staff present have a criminal record clearance and are associated with the facility. Resident files reviewed had updated physician's reports and signed admission agreements. The living room fireplace is adequately screened. LPA observed several board games, puzzles and activities available for resident use. Long Term Care Ombudsman's contact information, complaint procedures, facility sketch and emergency phone numbers are visibly posted near the front entrance.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Austria.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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