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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604230
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:34:05 PM

Document Has Been Signed on 08/20/2024 02:34 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:KELLY'S EASTBURY VILLAFACILITY NUMBER:
374604230
ADMINISTRATOR/
DIRECTOR:		MARYLINE SIADTOFACILITY TYPE:
740
ADDRESS:739 EASTBURY VILLATELEPHONE:
(619) 504-5049
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 6DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Garrett Welker, House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 08/20/24 at 12:20pm Licensing Program Analyst (LPA), Javina George made an unannounced visit to the facility for the purpose of conducting a 1yr required annual inspection. LPA George met with House Manager Garrett Welker and explained the purpose of the visit. The facility has an approved hospice waiver for (6) with (2) resident's that are currently receiving hospice services.

A facility file review was conducted on 08/1/24, LPA observed for the facility corporation governing body to be active. In addition LPA observed annual fees to be due on 08/12/24. During today's visit LPA observed for the balance to still not be paid. LPA inquired and was informed that the payment was submitted on or around 08/01/24.

The facility was observed to have a sufficient food supply, as there was a 7 day supply of non-perishable and a 2 day supply of perishable food items.The facility was observed to be clean, clutter and odor free. The passageways are free from obstruction. There are no known guns or ammunition, or pools or bodies of water on the premises. The facility conducts emergency disaster drills on a quarterly basis, the last drill was conducted on 08/05/24. The facility has (2) fully charged fire extinguishers. The medications were observed to be locked in two separate storage containers, located inside of the kitchen. The sharps and chemicals were observed to locked and inaccessible to residents in care. The smoke and carbon monoxide detectors were tested and found to be operable.

LPA conducted a file review of both staff and resident files. LPA observed for the resident files to have the required forms such as assessments, and admissions agreements. Regarding staff files, LPA observed for all staff present at the facility to have obtained proper fingerprint clearance and to be associated to the facility. The facility Administrator Maryline Siadto was observed to possess a valid administrator certificate, that expires on 10/29/24.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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 2
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 EASTBURY VILLA
FACILITY NUMBER: 374604230
VISIT DATE: 08/20/2024
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While conducting a tour of the interior of the facility LPA observed for the facility to utilize video surveillance inside bedroom #6 Resident #4 (R4) room, LPA observed for there to be a signed consent from the responsible party, R4 is also in a private room. The monitor is stored inside the kitchen, and the purpose of the monitoring is for safety reasons associated with R4's behaviors

Based on today's inspection no citations were issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report was provided to House Manager Garrett Welker.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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