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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604672
Report Date: 07/20/2023
Date Signed: 07/20/2023 12:55:51 PM

Document Has Been Signed on 07/20/2023 12:55 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:GLENFLORA MANORFACILITY NUMBER:
374604672
ADMINISTRATOR:BALINTONA, RUCHELLEFACILITY TYPE:
740
ADDRESS:6915 GLENFLORA AVENUETELEPHONE:
(619) 463-5757
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 6CENSUS: 6DATE:
07/20/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Applicant's Representatives, Principal Joseph Li and Administrator Ruchelle AgregadoTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen 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 himself to, and explained the purpose of the visit to the applicant's representatives, Principal Joseph Li and Administrator Ruchelle Agregado.

The facility fire clearance was granted on 04/25/2023 and reflects that the facility was approved for six (6) residents in total, of which five (5) may be non-ambulatory and one (1) may be bedridden. Only Bedroom #4, per the facility sketch, is approved for a bedridden resident. (During today's visit, there were also no bedridden residents presently in care.) The facility's fire clearance did not include endorsements for delayed-egress doors or secured perimeter, and neither were present during today's visit. The submitted facility sketch was consistent with the current layout of the facility.



During today’s visit, LPA, accompanied by the applicant's representatives, 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. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets, sinks, and showers were in working order. The facility’s ambient internal temperature was complaint at 71 degrees F. Hot water temperature at taps accessible to residents were also compliant: Kitchen sink was 113.5 F, Bathroom #1 sink was 110.3 F, Bathroom #2 sink was 108.5 F, and Bathroom #3 sink was 106.3 F.

The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for resident use. Kitchen appliances were in working order. Kitchen Refrigerator temperature was 37 F, and Kitchen Freezer temperature was 0 F. Medication Refrigerator temperature was 34 F. Garage Refrigerator temperature was 37 F, and Garage Freezer temperatures were 0 F and -4 F, respectively. [CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GLENFLORA MANOR
FACILITY NUMBER: 374604672
VISIT DATE: 07/20/2023
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[CONTINUED FROM LIC 809]

The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential resident and staff records.

No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. 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. Fire extinguishers were serviced within the last 12 months. A complete first aid kit was present. Required licensing postings were observed in visible areas of the facility.


The items reviewed were complaint with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. The applicant passed the pre-licensing inspection.

LPA also provided the Component III Training during today’s visit. Li and Agregado were advised that the facility’s application is pending management final review and approval.

An exit interview was conducted with the applicant's representatives, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC809 (FAS) - (06/04)
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