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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604619
Report Date: 04/17/2023
Date Signed: 04/17/2023 10:40:59 AM

Document Has Been Signed on 04/17/2023 10:40 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MAYFLOWER HOME CARE LLCFACILITY NUMBER:
374604619
ADMINISTRATOR:AMBAL, EUNICE P.FACILITY TYPE:
740
ADDRESS:7404 SKYLINE DRIVETELEPHONE:
(619) 230-5348
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 6CENSUS: DATE:
04/17/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Applicant Eunice AmbalTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified themselves to, and explained the purpose of the visit to applicant Eunice Ambal.

The facility fire clearance was granted on 1/3/2023 and reflects that the facility was approved for six (6) clients in total, of which two (2) can be ambulatory, two (2) can be non-ambulatory and one (1) can be bedridden.

During today’s visit, LPA, accompanied by the applicant toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Client bedrooms allowed for easy passage and contained the required furnishings. Toilets, sinks, and showers were in working order. Water temperature at taps accessible to clients were compliant: Bathroom #1 was 118 F and Bathroom #2 was 115 F and Kitchen was 118 F.

[Continued on LIC 809-C]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2023
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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MAYFLOWER HOME CARE LLC
FACILITY NUMBER: 374604619
VISIT DATE: 04/17/2023
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[Continued from LIC 809]

The facility has enough linens, hygiene supplies, dining supplies future client use. Refrigerator temperature was 40 F, and freezer temperature was 0 F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and client activities. The facility has locked areas for storage of medication and confidential client and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons or open-faced heaters accessible to clients. Per the applicant, no firearms or ammunition are or will be stored at the facility.

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. One (1) fire extinguishers and one (1) first aid kits were present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6 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. The applicant were 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 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC809 (FAS) - (06/04)
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