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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603328
Report Date: 04/03/2024
Date Signed: 04/03/2024 11:54:12 AM

Document Has Been Signed on 04/03/2024 11:54 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ARBOR VICTORIAFACILITY NUMBER:
374603328
ADMINISTRATOR:RICHARD M AXTELLFACILITY TYPE:
740
ADDRESS:3410 HIGHLAND DRIVETELEPHONE:
(760) 729-4800
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY: 6CENSUS: 6DATE:
04/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Admistrator Richard AxtellTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Ryan Fulton and Nacole Patterson conducted an unannounced Case Management visit to amend reports for a visit conducted on 3/19/24. LPAs identified themselves and discussed the purpose of the visit with Administrator Richard Axtell.

During today’s visit, LPAs obtained signatures on the amended reports. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC809-D).

A Plan of Correction was jointly developed with the Administrator. An exit interview was conducted with Administrator Richard Axtell, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Ryan Fulton
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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Document Has Been Signed on 04/03/2024 11:54 AM - It Cannot Be Edited


Created By: Ryan Fulton On 04/03/2024 at 11:02 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ARBOR VICTORIA
FACILITY NUMBER: 374603328

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2024
Section Cited
CCR
87555(b)(8)

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87555(b) "The following food service requirements shall apply: (8) All food shall be of good quality..." This requirement was not met, evidenced by: Expired canned goods were found in the pantry during the annual inspection visit on 3/19/24.
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Administrator agreed to immediagely discard all expired food items and regularly check food for expiration dates and discard or use by the expiration date.
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This posed a potential health and safety risk to 6 of 6 persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jennifer Lott
LICENSING EVALUATOR NAME:Ryan Fulton
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


LIC809 (FAS) - (06/04)
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