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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604490
Report Date: 12/19/2024
Date Signed: 01/08/2025 08:04:52 AM

Document Has Been Signed on 01/08/2025 08:04 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:COLLEGE TOWN SENIOR RETIREMENT VILLA INCFACILITY NUMBER:
374604490
ADMINISTRATOR/
DIRECTOR:
PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:5252 STONE CTTELEPHONE:
(619) 432-1236
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY: 6CENSUS: 6DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:45 AM
MET WITH:Care giver Wendy GomezTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA's) Amy Rodgers and Angelica Boyles conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted by, identified themselves to, and discussed the purpose of the visit to Caregiver Gomez. LPA Rodgers also discussed the visit over the phone with licensee Anna Petrosyan.

According to the facility’s license, the facility has a maximum capacity of six (6) residents all of whom can be non-ambulatory, and a waiver for four (4) residents on hospice. During today's inspection, there were a total of six (6) residents in care, of which one (1) received hospice care. This facility does not feature a secured perimeter or delayed egress doors. Required licensing postings were observed in visible areas of the facility.

LPA, accompanied by Caregiver Gomez, 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 obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens, hygiene supplies, and Personal Protective Equipment (PPE) were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was compliant. The facility's hot water temperature for faucets used by residents measured at 118 F.

(continued on 809-C)

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: COLLEGE TOWN SENIOR RETIREMENT VILLA INC
FACILITY NUMBER: 374604490
VISIT DATE: 12/19/2024
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There was no pool or large bodies of water on the premises. According to Caregiver Gomez, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility landline telephone were all working. Fire extinguisher was present. First aid kit and first aid manual were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and reviewed multiple staff and client records/files. The interviews did not raise any licensing concerns. The resident and staff files contained the required documents. Confidential records, medications, and toxins were inaccessible to residents in care.

During today's visit, no deficiencies were observed. An exit interview was conducted with Caregiver Gomez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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