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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881713
Report Date: 07/29/2025
Date Signed: 07/29/2025 11:19:20 AM

Document Has Been Signed on 07/29/2025 11:19 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KELLY'S GRAND VILLAFACILITY NUMBER:
371881713
ADMINISTRATOR/
DIRECTOR:		BALDOVINO, COLTFACILITY TYPE:
740
ADDRESS:300 AMPARO DRTELEPHONE:
(442) 257-2053
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 6CENSUS: 0DATE:
07/29/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator, Colt BaldovinoTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 7/29/25, Licensing Program Analyst (LPA) Valerie Flores made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA Flores met with Administrator, Colt Baldovino, who accompanied LPA for the tour of the facility. The Applicant has submitted an application to attain a capacity of (6) six residents. On 04/23/25 the City of Escondido Fire Department approved a fire clearance for the six (6) non-ambulatory and (0) zero bedridden residents. A tour of the interior/exterior were conducted. LPA observed the following during today's inspection:

The facility is a single-story structure building consisting of one (1) staff bedroom, five (5) residents' bedrooms, (3.5) three and a half bathrooms, a kitchen, dining room, living room, great room, and garage. The bedrooms were observed to have met the required bedding, lighting, and furniture. There are plenty of extra linen (sheets, blankets, towels) that were observed to be in good repair located in the hall closet. LPA observed a fully charged fire extinguisher. LPA observed a fully stocked first-aid kit located in a locked cabinet in the hallway. A locked cabinet in the kitchen was observed to store knives and other sharp objects. The carbon monoxide and smoke detector were tested and were observed to be operable and in good working condition. The facility has more than a two (2) day supply of perishable foods and seven (7) day supply of non-perishable foods. Kitchen/food preparation areas were kept clean from litter and rubbish. Resident showers are equipped with slip-resistant strips and grab bars. The outdoor patio is shaded and furnished.

(Continue to LIC809C...)

NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
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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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 GRAND VILLA
FACILITY NUMBER: 371881713
VISIT DATE: 07/29/2025
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 (Continuation from LIC809)

The facility has a sufficient supply of dishes, cooking and eating utensils, that were observed to be in good repair. Centrally stored medication is kept in a locked cabinet that is inaccessible to residents in care. All indoor and outdoor passageways were free of obstruction. The hot water temperature was measured at 105.2 degrees Fahrenheit meeting the required limits. The facility has an emergency disaster plan and approved infection control training plan on file. Per Administrator, Colt Baldovino, there are no firearms or ammunition on the premises.

LPA observed the required postings of the emergency disaster plan, resident personal rights, employee rights, emergency contacts, facility sketch, CCL Complaint poster and the Long-Term Care Ombudsman poster posted on the walls throughout the facility.

During today's visit, LPA Flores did not observe any issues or concerns. Final approval of licensure will be determined by Centralized Application Bureau (CAB). An exit interview and a copy of this report was given to Administrator, Colt Baldovino.

NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
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