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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601334
Report Date: 04/17/2024
Date Signed: 04/18/2024 08:09:48 AM

Document Has Been Signed on 04/18/2024 08:09 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:SERRA MESA GUESTS HOME III, LLCFACILITY NUMBER:
374601334
ADMINISTRATOR/
DIRECTOR:
SALAZAR, EVELYNFACILITY TYPE:
740
ADDRESS:3008 MELBOURNE DRTELEPHONE:
(858) 277-6515
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY: 6CENSUS: 6DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Evelyn Salazar, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was met by Caregivers, Danilo Samonte and Joy Singson. Licensee, Evelyn Salazar, arrived later and LPA discussed with Ms. Salazar, the purpose of the visit. All staff present possessed a current criminal record clearance. Salazar is the Certified Administrator for the facility.

LPA conducted a tour of the facility, both inside and outside. There were two (2) staff members to provide for the residents in care. The residents all stated that they were treated with dignity by facility staff and produced no concerns in their interviews. The facility is operating in accordance with their fire clearance. The smoke and carbon monoxide alarms were present. Caregiver, Samonte stated that there are no firearms stored on the premises. The facility thermostat read at 77.0 degrees F. Hot water temperatures measured 111.3- and 111.7-degrees F in the resident bathrooms and 113.4 at the kitchen sink. Each toilet and bathtub/shower had grab bars for resident use and each bathtub/shower had nonskid mats or strips. Each resident room had sufficient lighting.

The facility exceeded the minimum of one (1) week of nonperishable foods and a minimum of two (2) days of fresh perishable foods. Medications are centrally stored and secured in the kitchen. Facility records were also reviewed. The disaster plan was available in the hallway by the kitchen and was updated April 17, 2024. On 1/27/2024, facility coordinated a fire/earthquake drill per the facility log.

Staff records were reviewed and indicated current training including, medications and prohibited conditions. Review of Resident records indicate that in each of the files reviewed, there is a current Medical Assessment, and an Admission Agreement. Ms. Salazar provided the declaration sheet for the facility's current liability insurance. The coverage amounts, meet minimum requirements as required, and expires on 03/28/2025. Licensing and infection control postings were prominently placed.

[Continued on LIC8090-C]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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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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: SERRA MESA GUESTS HOME III, LLC
FACILITY NUMBER: 374601334
VISIT DATE: 04/17/2024
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[Continued from LIC-809]


No deficiencies were cited during today’s inspection.

An exit interview was conducted, and a copy of this report was provided to Ms. Salazar, and she was provided a copy of the Licensee/Appeal rights (LIC9058 01/16). Ms. Salazar’s signature on this form, acknowledges receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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