<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604425
Report Date: 07/23/2024
Date Signed: 07/23/2024 03:10:34 PM

Document Has Been Signed on 07/23/2024 03:10 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:LA JOLLA CASA FIESTAFACILITY NUMBER:
374604425
ADMINISTRATOR/
DIRECTOR:
FERNANDEZ, JENNIFERFACILITY TYPE:
740
ADDRESS:5426 AVENIDA FIESTATELEPHONE:
(858) 775-6935
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY: 6CENSUS: 6DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:House Manager Hermelinda GonzalezTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to House Manager Hermelinda Gonzalez. The facility was licensed for a capacity of six (6) non-ambulatory residents, of which one (1) may be bedridden in room # 1. The facility also had a hospice waiver for two (2) residents.

The LPA, accompanied by House Manager, 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 obstructions and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored.
Cooking, dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients.
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. Carbon monoxide detector, and facility telephone were all working. A fire extinguisher was present. Required licensing postings were observed in visible areas of the facility.

The LPA interviewed staff and reviewed multiple staff and client records/files. The LPA provided Technical Advise to the house manger. No deficiencies were cited on today's date.

An exit interview was conducted with House Manager Gonzalez, 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: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 1