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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604273
Report Date: 04/18/2024
Date Signed: 04/19/2024 08:28:56 AM

Document Has Been Signed on 04/19/2024 08:28 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:CASA MAHALFACILITY NUMBER:
374604273
ADMINISTRATOR/
DIRECTOR:		FRAZIER, THERESAFACILITY TYPE:
740
ADDRESS:12631 CASA AVENIDATELEPHONE:
(858) 924-1136
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 6DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Caregivers Jay-Ronn and Tersita DuclayanTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct an annual licensing inspection. LPA identified herself to Caregiver Duclayan and explained the purpose of the visit. The facility is licensed to six (6) residents of whom five (5) must be ambulatory, one bed-ridden (1), and 5 receiving hospice services.

During today’s visit, LPA Correia conducted a partial interior tour of the facility and resident records reviews. LPA also briefly spoke to a resident in care and interviewed facility staff. An overall inspection of the facility began today. However, due to time constraints LPA was unable to complete the visit and will return later time to conduct the remaining portion of this inspection.


No deficiencies were cited during today's visit. This report was discussed with Caregiver Duclayan. A copy of the report and License Rights (01/2016) will be provided at the conclusion of the visit, and signature on this form acknowledges receipt of the rights and a copy of this report.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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