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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604610
Report Date: 02/05/2025
Date Signed: 02/05/2025 12:56:44 PM

Document Has Been Signed on 02/05/2025 12:56 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:LIFE SAVER PLACE OF OCEANSIDE IIFACILITY NUMBER:
374604610
ADMINISTRATOR/
DIRECTOR:		BALANQUIT, IEZL L.FACILITY TYPE:
740
ADDRESS:113 POLK STTELEPHONE:
(760) 305-7651
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 5DATE:
02/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Assistant Administrator Amyrose UndagTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Rogelio Magaya. Assistant Administrator Amyrose Undag arrived during the visit.

The facility is licensed for a maximum capacity of 6 non-ambulatory residents, 1 of which may be bedridden in bedroom #1. The facility has a waiver for 2 hospice residents. During today’s visit, the facility had a census of 5 non-ambulatory residents. The Administrator for the facility is Iezl Balanquit and their certificate was valid and current.

During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 111.0 degrees Fahrenheit in the facility kitchen and 110.8 degrees Fahrenheit in a common bathroom for resident use. The facility’s internal temperature was measured at 73 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Amyrose Undag, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 37 degrees Fahrenheit, and the facility freezer was kept at -5 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs.
Continued on LIC809-C page…
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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: LIFE SAVER PLACE OF OCEANSIDE II
FACILITY NUMBER: 374604610
VISIT DATE: 02/05/2025
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Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, initial physician’s report and updated medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

No deficiencies were cited on today’s date. An exit interview was conducted with Assistant Administrator Amyrose Undag, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
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