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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604500
Report Date: 02/17/2022
Date Signed: 02/17/2022 10:27:51 PM

Document Has Been Signed on 02/17/2022 10:27 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:CALLE DE VIDAFACILITY NUMBER:
374604500
ADMINISTRATOR:YACOUB, JUMANFACILITY TYPE:
740
ADDRESS:4745 CALLE DE VIDATELEPHONE:
(825) 694-0265
CITY:SAN DIEGOSTATE: CAZIP CODE:
92124
CAPACITY: 6CENSUS: 6DATE:
02/17/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Applicant Juman YacoubTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant and records for compliance with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code. LPA was greeted by, identified themselves to, and explained the purpose of the visit to applicant Juman Yacoub.

The facility fire clearance was granted on December 16, 2021 and reflects that the facility is approved for six (6) non-ambulatory residents.

During today’s visit, LPA, accompanied by the applicant, toured the interior and exterior of the facility and inspected each room. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets and showers were in working order. The facility’s ambient internal temperature was 77 degrees F. Water temperatures were compliant as follows: Kitchen was 115.2 F, Bathroom #1 was 109 F, Bathroom #2 was 110.7 F, Bathroom #3 was 106.2 F, Bathroom #4 was 115.3 F, Bathroom #5 was 107 F, and Bathroom #6 was 119 F.

The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for future resident use. Refrigerator temperature was 39 F, and freezer temperature was 0 F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant, no firearms or ammunition are or will be stored at the facility. [CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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: CALLE DE VIDA
FACILITY NUMBER: 374604500
VISIT DATE: 02/17/2022
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[CONTINUED FROM LIC 809]

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. One fire extinguisher and two first aid kits were present. Required licensing postings were observed in visible areas of the facility. The facility has locked areas for storage of medication and confidential staff and resident records. Staff and resident records contained the required elements.

The items reviewed were complaint with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code. The applicant passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. Yacoub was advised that the facility’s application is pending management final review and approval. An exit interview was conducted with the applicant, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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