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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604697
Report Date: 08/01/2023
Date Signed: 08/01/2023 12:50:54 PM

Document Has Been Signed on 08/01/2023 12:50 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:FAITH VILLAFACILITY NUMBER:
374604697
ADMINISTRATOR:DEGUZMAN,MA. MEVYLFACILITY TYPE:
740
ADDRESS:42 SIERRA WAYTELEPHONE:
(732) 829-1627
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 4DATE:
08/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Applicants Representatives, Aries Deguzman and Ma. Mevyl Deguzman TIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced 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, Aries Deguzman and Ma. Mevyl Deguzman.

The facility fire clearance was granted on 06/21/2023 and reflects that the facility was approved for six (6) residents in total, of which all may be non-ambulatory, but none may be bedridden. As of today's visit, the four (4) residents in care were all non-ambulatory. The facility's fire clearance did not include delayed-egress door or secured perimeter endorsements, 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 compliant at 77 degrees F. Hot water temperature at taps accessible to residents were also compliant: Kitchen sink was 111 F, Bathroom #1 sink was 106.2 F, Bathroom #2 sink was 108.5 F, and Bathroom #3 sink was 108.1 F.

The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for resident use. All kitchen appliances were in working order. Kitchen Refrigerator temperature was 39 F, and Kitchen freezer temperature was 0 F. Garage Refrigerator temperature was 39 F, and Garage Freezer temperatures were 0 F and -5 F, respectively.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
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: FAITH VILLA
FACILITY NUMBER: 374604697
VISIT DATE: 08/01/2023
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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 detector, 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. The Deguzmans 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: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC809 (FAS) - (06/04)
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