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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601302
Report Date: 10/19/2023
Date Signed: 10/20/2023 07:35:39 AM

Document Has Been Signed on 10/20/2023 07:35 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MISSION HOME IIIFACILITY NUMBER:
374601302
ADMINISTRATOR:CURMAK, CERENFACILITY TYPE:
740
ADDRESS:2493 MELBOURNE DRIVETELEPHONE:
(858) 560-7676
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY: 6CENSUS: 5DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Susana Baragan, CaregiverTIME COMPLETED:
01:00 PM
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On 10/19/2023, at about 10:00 AM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Susana Baragan, Caregiver. According to the facility’s license, the facility serves six (6) non-ambulatory elderly residents, age 60 and above. The facility had an Infection Control Plan which LPA reviewed and noted no concerns.

LPA Pena toured the interior and exterior of the facility and inspected each resident’s room. The facility was organized, kempt, in good repair and contained no offensive odors. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Bathroom had grab bars at toilet and shower used by residents. Non-skid mat was observed in shower. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

There was at least two days of perishable food, and at least seven days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked cabinet.

No pools or bodies of water were observed on the premises. Per Caregiver, Baragan, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible.

Required licensing postings were observed in visible areas of the facility. Hot water temperatures measured in the resident restroom and kitchen were within Title 22 Regulations. LPA interviewed staff and residents and reviewed staff and resident records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MISSION HOME III
FACILITY NUMBER: 374601302
VISIT DATE: 10/19/2023
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[CONTINUED FROM LIC 809]

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Caregiver, Baragan to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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