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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604452
Report Date: 08/27/2021
Date Signed: 08/27/2021 06:09:26 PM

Document Has Been Signed on 08/27/2021 06:09 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:MISSION CAREHOME SOUTHFACILITY NUMBER:
374604452
ADMINISTRATOR:LIMPIN, ROSEMARIEFACILITY TYPE:
740
ADDRESS:2534 NYE STTELEPHONE:
(619) 777-9674
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY: 6CENSUS: 0DATE:
08/27/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Alexander Limpin, LicenseeTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an announced Pre-Licensing inspection at a Residential Care Facility for the Elderly on today's date to inspect the facility for compliance with Title 22, Division 6, Chapter 8 of the California Code of Regulations and the Health & Safety Code. After arriving at the facility, LPA identified herself, disclosed the purpose of the visit and was granted entry by Alexander Limpin, Potential Licensee.

LPA toured the physical plant, inside and out, and observed the following: Resident accommodations were in compliance with regulations, including furnishings, linens, and personal hygiene items; resident bathrooms were equipped with non-skid mats, and water temperature measured at 111 degrees Fahrenheit (F)and 109.6 degrees F in bathrooms used by residents and the kitchen water temperature measured at 108 degrees F; the facility’s ambient room temperature was 85 degrees F at the time of the visit; medications will be stored in a drawer but the locking mechanism was not installed at the time of the visit. Staff and resident records were not kept in a secured area in the dining area; food service was within the requirements of regulations, including dishes, utensils, food storage, and licensee understands that a seven (7) day supply of non-perishables and the two (2) day supply of perishables will be bought once residents are admitted. Knives and sharp objects were in an accessible area; toxic substances were stored in a cabinet under the sink area which was accessible; first aid kits and first aid manuals and required supplies were stored in the medication drawer; activities, supplies and sufficient space in which to conduct activities were present; fire extinguisher was present at the facility; smoke and carbon monoxide detectors were present and operable; required facility postings were present and visible in the common area of the facility. According to the potential Licensee, there are no guns, weapons, or ammunition stored on the facility property. The facility does not have a swimming pool or bodies of water.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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: MISSION CAREHOME SOUTH
FACILITY NUMBER: 374604452
VISIT DATE: 08/27/2021
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LPA will complete the Component III with the potential Licensee at the next visit once deficiencies have been corrected. Deficiencies were observed during today's visit are not in compliance with Title 22, Division 6, Chapter 8 of the California Code of Regulations and the Health and Safety Code. The Licensee was advised that at this time the facility will need to correct the deficiencies prior to licensing the facility. An exit interview was conducted with Mr. Limpin and a copy of this report and Applicant Rights (LIC 9058) were provided to him via electronic mail. LPA requested for Licensee to send a confirmation of receipt of these documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC809 (FAS) - (06/04)
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