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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604362
Report Date: 11/15/2024
Date Signed: 11/15/2024 12:17:04 PM

Document Has Been Signed on 11/15/2024 12:17 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:UC CARE SENIOR LIVING IIFACILITY NUMBER:
374604362
ADMINISTRATOR/
DIRECTOR:
DEREK POSADAFACILITY TYPE:
740
ADDRESS:3739 MILLIKIN AVETELEPHONE:
(858) 203-1160
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY: 6CENSUS: 6DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Caregiver Beatriz JimenezTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs), Sabel Martinez and David Roman, conducted an unannounced Required Annual Inspection. The LPAs introduced themselves and disclosed the purpose of the visit with Caregiver Beatriz Jimenez. The facility was licensed for six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility also had a hospice waiver approved for five (5) residents.

The LPAs and caregiver toured the interior and exterior of the facility, and inspected resident bedrooms. The facility
was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Bedrooms
contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. 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 of non-perishable food present, all safely stored.
Cooking, dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents.
Medications were labeled, and stored in a locked area.

No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. A carbon monoxide detector, facility telephone, fire extinguisher, and first aid kit were accessible. Required licensing postings were observed in visible areas of the facility.

The LPA interviewed staff and reviewed multiple staff and client records/files. The files which LPA reviewed contained
required documents. Confidential records were stored in a locked area. No deficiencies were cited during today's annual inspection. An exit interview was conducted with Caregiver Jimenez, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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