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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604505
Report Date: 02/05/2024
Date Signed: 02/05/2024 04:03:46 PM

Document Has Been Signed on 02/05/2024 04:03 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:UC SENIOR CARE IVFACILITY NUMBER:
374604505
ADMINISTRATOR:DEREK POSADAFACILITY TYPE:
740
ADDRESS:3810 GOVERNOR DRIVETELEPHONE:
(858) 583-6431
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY: 6CENSUS: 6DATE:
02/05/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Caregivers Beatriz Jimenez and Maria MorenoTIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management- Annual Continuation visit. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Maria Moreno. Caregiver Beatriz Jimenez arrived during the visit and assisted the LPA. The facility was licensed for a capacity of six (6) non-ambulatory residents with an approved hospice waiver for five (5) hospice residents.

During the annuals visits, the LPA 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. Client bedrooms
contained the required furnishings. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored.
Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients.
Medications were labeled and stored in locked areas.

No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon monoxide detectors, and facility telephone were all working. A fire extinguisher and first aid kit were 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 files which LPA reviewed contained
required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Caregiver Beatriz Jimenez. A copy of this report, and the Licensee/Appeal Rights
(LIC9058), were sent to the administrator via email. An email read receipt confirms the documents were received by the administrator.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2024
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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