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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604641
Report Date: 03/21/2025
Date Signed: 03/21/2025 04:12:04 PM

Document Has Been Signed on 03/21/2025 04:12 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:POWAY GARDENS SENIOR LIVING - SYCAMORESFACILITY NUMBER:
374604641
ADMINISTRATOR/
DIRECTOR:
SHANNON HUNDLEYFACILITY TYPE:
740
ADDRESS:12738 MONTE VISTA ROADTELEPHONE:
(658) 674-1255
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 0DATE:
03/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Resident Services, Sherryl AndingTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) David Roman conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA identified himself to and discussed the purpose of the visit with Resident Services Dir., Sherryl Anding. According to the facility’s license, the facility has a maximum capacity of six clients, of whom all may be non-ambulatory and approved for delayed egress, waiver granted for hospice care, dementia plan submitted. The facility has been empty since its pre-licensing visit on 03/13/24.

LPA along with facility staff toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms were empty and would contain the required furnishings once residents are admitted. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

Cooking/dining equipment and utensils will be present when residents become admitted. There were no toxic chemicals/poisons accessible. Medications will be locked and stored in a locked area once residents are admitted.

No pools or bodies of water on the premises. Per administration, no firearms or ammunition are kept at the facility. Fire alarms and carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit was complete and readily accessible.

An exit interview was conducted with Resident Services Dir., Sherrly Anding to whom a copy of this report and the Licensee/Appeal Rights were provided during the visit. Their signature acknowledges the receipt of this report and their rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: David Roman
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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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