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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604791
Report Date: 06/21/2024
Date Signed: 06/21/2024 05:21:32 PM

Document Has Been Signed on 06/21/2024 05:21 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:SIMA COURT RCFEFACILITY NUMBER:
374604791
ADMINISTRATOR/
DIRECTOR:
MASE, DOMINIQUE JOHN O.FACILITY TYPE:
740
ADDRESS:10726 SIMA COURTTELEPHONE:
(619) 405-3586
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY: 4CENSUS: 0DATE:
06/21/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Applicant Dominique MaseTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an announced Pre-Licensing visit. LPA was joined by Applicant, Dominique Mase, and granted entry into the facility. The purpose of the visit was to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The Fire Department granted fire clearance on February 6, 2024.

During today's visit, LPA Correia, accompanied by applicant Mase, toured the facility inside and outside and inspected every room. The facility was found to be in good repair with no pathway obstructions. Clients' bedrooms were observed to be clean; required furnishings were present. The facility's ambient temperature was 66 degrees F during the visit. Toilets were found to be in working order. Hot water temperature in client bathroom measured at 105.4 degrees F. Hazardous and/or toxic chemicals will be stored and secured in locked cabinets that are inaccessible to clients. Locked cabinets will be used for storage of medications and client and staff records. There was a first aid kit and manual present in the facility. The facility has sufficient space in which to conduct activities. Smoke and carbon monoxide detectors were present and were recently inspected by the local fire authority. No pools or bodies of water were observed near or on the premises. According to the applicant, no firearms and/or ammunition present or will be stored in the facility. Sufficient and appropriate storage was present to store perishable and non-perishable food items. Required postings were present and posted in a visible area of the facility. Component III was conducted during today’s visit.

This report was discussed with the applicant. Applicant will be provided a copy of the report at the conclusion of the visit. Signature below confirms receipt of the report.

LPA left the facility for an hour lunch break during the visit.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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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