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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604439
Report Date: 08/17/2021
Date Signed: 09/03/2021 03:01:55 PM

Document Has Been Signed on 09/03/2021 03:01 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:KELLY'S CEDAR VILLAFACILITY NUMBER:
374604439
ADMINISTRATOR:ROSAS, KELSEY LVNFACILITY TYPE:
740
ADDRESS:1341 BOYLE AVENUETELEPHONE:
(619) 504-5049
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 6DATE:
08/17/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:30 PM
MET WITH:Garrett Welker, Lead CaregiverTIME COMPLETED:
11:45 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) Liliana Silveira conducted an unannounced visit to conduct a post-licensing inspection to ensure that the facility is operating in compliance with California Code of Regulations, Title 22, Division 6. LPA introduced themselves, disclosed the purpose of the visit and was granted entry into the facility by Lead Caregiver Garrett Welker.

A tour of the facility was conducted inside and out. LPA conducted a general overall inspection, which included, but was not limited to, the following: facility physical plant, food service, medication management, records review, and facility administration.

During today's inspection, LPA observed the following: All indoor and outdoor passageways were free from obstructions. The facility’s indoor temperature was 71 degrees Fahrenheit. No pools or bodies of water were observed. According to Garrett Welker, there are no firearms or ammunition stored in the facility. Cleaning supplies and toxins were locked and inaccessible to the residents. LPA toured resident bedrooms. The rooms had the required furnishings and sufficient lighting. Licensee provided the residents with clean linens, in good repair, and sufficient hygiene products for personal use. The hot water temperature in resident bathroom #1 measured 118.8, bathroom #2 116.4, bathroom #3 119.7, bathroom #4 119.3 and bathroom #5 114.4 degrees Fahrenheit. Bathroom #6 was inaccessible. The facility had functioning carbon monoxide detectors and smoke detectors that met statutory regulations.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: KELLY'S CEDAR VILLA
FACILITY NUMBER: 374604439
VISIT DATE: 08/17/2021
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
26
27
28
29
30
31
32
The facility was stocked with a two (2) day supply of perishable and seven (7) day supply of nonperishable food items. Medications were stored in a locked cabinet and were labeled and maintained in compliance with label instructions. Staff present had criminal record clearance and current first aid certification on file. The resident files contained current records. Licensee does not currently secure resident cash resources. LPA observed the required postings in a prominent place in the facility. Administrator Certification for Kelsey Rosas expires 01/27/23.

Based on today’s visit there were no deficiencies cited in the areas above. An exit interview was conducted with Lead Caregiver Garrett Welker and a copy of this report and Licensee/Appeal Rights (LIC9058 01/16) were provided to the Licensee via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2