374604478-12-22-2021-08-AS-KRYN-C9XLT3-20211222080136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604478
Report Date: 12/21/2021
Date Signed: 12/22/2021 08:02:00 AM

Document Has Been Signed on 12/22/2021 08:02 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	SOUTH PACIFIC VILLA		FACILITY NUMBER:	374604478
ADMINISTRATOR:	PRONOVOST, SHANEL		FACILITY TYPE:	740
ADDRESS:	543 GUIDERO WAY		TELEPHONE:	(916) 768-6948
CITY:	ENCINITAS	STATE: CA	ZIP CODE:	92024
CAPACITY: 6		CENSUS: 6	DATE:	12/21/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:	Administrator, Shanel Pronovost		TIME COMPLETED:	12:00 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), Kristina Ryan conducted an announced Pre-Licensing inspection. LPA identified herself to Administrator, Shanel Pronovost., and explained the purpose of the visit which was to evaluate Title 22 compliance for a Change of Ownership application. The facility plans to serve elderly residents, ages 60 and over. The Fire Clearance was granted on July 16, 2021. Facility is approved for 6 residents, 4 of whom can be non-ambulatory. Facility is approved for 2 bedridden residents. An inspection of the facility was conducted inside and out. All resident rooms were observed. Bathrooms are equipped with toilets, and hand-washing and bathing facilities are sanitary and in operating condition. LPA was unable to check the water temperature due to the water temporarily being turned off by the city due to a broken pipe on the street. .Administrator provided a water temperature log for LPA to review. Last temperature recorded on 12/20/2021 was 113.5 Fahrenheit. Each room was set at a comfortable temperature. All lighting fixtures and facility windows were operable and in good condition. Outdoor and indoor passageways were free from obstructions. Fire extinguishers were affixed with current tags. Smoke and carbon monoxide detectors were present and operational. There were no pools or other bodies of water observed on the premises. Locked cabinets and storage areas were identified to store toxic substances, knives, and medication. Hazardous items were stored such that they were inaccessible to residents. Per Administrator Pronovost, no weapons or ammunition are or will be stored at the facility.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Kristina Ryan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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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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: SOUTH PACIFIC VILLA	FACILITY NUMBER: 374604478
	VISIT DATE: 12/21/2021

NARRATIVE

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LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Ms. Pronovost. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety.

LPA observed facility accommodations including food supplies, medication storage, first aid kit as well as toiletries and linens. Required CCLD postings were present. LPA reviewed a sampling of staff and resident records. Resident records that were reviewed included admissions agreements, physician's reports, and pre-placement appraisals. Staff records were reviewed for criminal background clearance, criminal record statement, and first aid/ CPR training. The administers Administrator Certification expires September 30, 2023. Component III was reviewed with administrator. The application will be sent to the Centralized Application Bureau for final review and approval.

An exit interview was conducted with Administrator, Shanel Pronovost. A copy of this report, along with the Licensee Rights (9058 01/16) was emailed to Ms. Pronovost at the conclusion of the visit, an electronic response confirms the receipt of these documents.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Kristina Ryan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

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