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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604489
Report Date: 12/31/2024
Date Signed: 01/03/2025 08:56:23 AM

Document Has Been Signed on 01/03/2025 08:56 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:AVALON PALM CARE, INC. DBA AVALON PALMFACILITY NUMBER:
374604489
ADMINISTRATOR/
DIRECTOR:
WINBLAD, JASONFACILITY TYPE:
740
ADDRESS:3271 INNUIT AVETELEPHONE:
(619) 757-3918
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 6CENSUS: 6DATE:
12/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Caregiver Malia SamuelaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection visit. The LPA introduced himself to and disclosed the purpose of the visit to Caregiver Malia Samuela. Administrator Magdarline Winblad arrived during the visit. The facility was licensed for a capacity of six (6) non-ambulatory residents, of which one (1) may be bedridden in bedrooms one through five. The facility also had an approved hospice waiver for four (4) residents.

The LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected bedrooms. The facility
was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order.

The facility had sufficient space to facilitate dining, visitation, meetings, and activities. No pools, nor bodies of water were observed on the premises. Per staff, no firearms nor ammunition were kept at the facility.

Due to time constraints, an additional visit on a subsequent day is necessary to complete the annual inspection. No deficiencies were cited during today's date.

An exit interview was conducted with Caregiver Malia Samuela. A a copy of this report, and the Licensee/Appeal Rights (LIC9058), were emailed to the administrator. An email read receipt confirms the documents were received.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
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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