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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604421
Report Date: 02/06/2026
Date Signed: 02/06/2026 11:18:15 AM

Document Has Been Signed on 02/06/2026 11:18 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:LA JOLLA VISTAFACILITY NUMBER:
374604421
ADMINISTRATOR/
DIRECTOR:		FERNANDEZ, GUSFACILITY TYPE:
740
ADDRESS:5720 DESERT VIEW DRTELEPHONE:
(858) 775-6935
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY: 6CENSUS: 0DATE:
02/06/2026
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Co-Administrator Jennifer FernandezTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an announced Case Management visit to the facility. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Co-Administrator Jennifer Fernandez. The purpose of today's visit was for LPA to conduct a walk-through of the facility at the request of Co-Administrator Fernandez and provide consultation on best practices and licensing resources prior to the facility beginning to accept new residents. The facility has not had any residents since the end of March 2025.

During today's visit, LPA and Co-Administrator Fernandez toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility is prepared to contain at least two (2) days of perishable food, and at least seven (7) days non-perishable food. Co-Administrator Fernandez showed LPA the locked cabinet designated for storage of knives and other sharp objects.

No pools or bodies of water exist on the premises. Per Co-Administrator Fernandez, no firearms or ammunition are kept at or planned to be kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

[Continued on LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: LA JOLLA VISTA
FACILITY NUMBER: 374604421
VISIT DATE: 02/06/2026
NARRATIVE
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[Continued from LIC 809]

While touring the side of the home containing bedrooms #4 and #5, LPA noted that the wall that created a hallway to access the two (2) rooms had been removed, thus increasing the size of the rooms. Additionally, the hall closet had been converted into a restroom. A door was placed in between the two rooms, however, per regulation 87307(a)(2)(C), resident rooms may not be used as access ways into another bedroom. This changes route access to bedroom #5, making it only accessible through the exterior door into the room from the yard, or through the garage into bedroom #5's private restroom. Per Co-Administer Fernandez, the route into room #5 through garage access was always what was used, and the previous hallway had not been, hence the removal of the hallway.

While the Licensee had submitted an updated facility sketch to the Department on January 5th, 2026 notating the changes to the floor plan, the Department had not received notification from the Licensee regarding proposed construction/alterations or applicable permits for changes to the home. Such modifications to the facility may be subject to inspection by the local Fire Authority. Though there are not any current residents in the home, a Type A citation is being issued for unapproved alterations and are noted on the attached LIC 809-D page. Additionally, as this is a violation pertaining to Fire Clearance Violations, a Zero-Tolerance Civil Penalty is being assessed in the amount of $500 and is noted in the attached LIC 421IM.

An exit interview was conducted with Co-Administrator Fernandez to whom a copy of this report, the LIC 421IM, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/06/2026 11:18 AM - It Cannot Be Edited


Created By: Arian Golbakhsh On 02/06/2026 at 10:51 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: LA JOLLA VISTA
FACILITY NUMBER: 374604421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2026
Section Cited
CCR
87305(b)

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87305(b): The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.

This requirement is not met as evidenced by:
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Licensee will submit a completed LIC 200 application to LPA, along with any applicable permits for the alterations conducted by POC due date.
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Based on LPA observation and interview, the licensee did not comply with the section cited above in ensuring the Department was notified of building alterations that would affect their fire clearance, which poses an immediate health, safety, and/or personal rights risk to 0 out of 0 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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2026


LIC809 (FAS) - (06/04)
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