374604525-2-10-2025-08-AS-AGOH-DDS36N-20250210165834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604525
Report Date: 02/10/2025
Date Signed: 02/10/2025 04:58:50 PM

Document Has Been Signed on 02/10/2025 04:58 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:	CANYON GUEST HOME		FACILITY NUMBER:	374604525
ADMINISTRATOR/ DIRECTOR:	RAPHAEL, DANIEL		FACILITY TYPE:	740
ADDRESS:	4224 EMET COURT		TELEPHONE:	(858) 285-0811
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92117
CAPACITY: 6		CENSUS: 6	DATE:	02/10/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:55 PM
MET WITH:	Administrator Daniel Raphael		TIME VISIT/ INSPECTION COMPLETED:	04:15 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) Arian Golbakhsh conducted an unannounced, Required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregiver Stephani Tita. The facility's license shows a maximum capacity of six (6) residents, all of whom must be non-ambulatory. The facility is approved for five (5) hospice residents. During today’s inspection there were six (6) residents in care. LPA and caregiver Ronald Rafanan toured the interior and exterior of the facility and inspected each room. Administrator Daniel Raphael arrived later during the visit. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Bathroom sink 1 read 105F and bathroom sink 2 read at 108F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents in care. [Continued on LIC 809-C]

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: CANYON GUEST HOME	FACILITY NUMBER: 374604525
	VISIT DATE: 02/10/2025

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
26
27
28
29
30
31
32

[Continued from LIC 809]

No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per caregiver Ronald Rafanan, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher was serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed two (2) staff and zero (0) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas.

No deficiencies were cited during the inspection. An exit interview was conducted with Administrator Daniel Raphael to whom a copy of this report was provided. Their signature below confirms receipt of this document.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

LIC809 (FAS) - (06/04)

Page: 2 of 2