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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604842
Report Date: 01/03/2025
Date Signed: 01/04/2025 08:52:45 PM

Document Has Been Signed on 01/04/2025 08:52 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:TAYABA'S HOMEFACILITY NUMBER:
374604842
ADMINISTRATOR/
DIRECTOR:		TAYABA, JOSEPHINE NFACILITY TYPE:
740
ADDRESS:8873 STANWELL STTELEPHONE:
(858) 232-6210
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6CENSUS: 0DATE:
01/03/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Applicant, Josephine TayabaTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA), Natasha Persaud conducted an announced second Prelicensing inspection. An initial application to operate a Residential Care Facility for the Elderly was received on 06/05/24. The facility was approved to care for six (6) Elderly Residents; four (4) Non-Ambulatory and two (2) Ambulatory. The purpose of the visit was to inspect items that required completion on the first prelicensing inspection was on 12/20/24. LPA was greeted and allowed entry into the facility by and met with Applicant, Josephine Tayaba.

Structure- The facility is a single story structure with 5 bedrooms and 2 bathrooms. No bodies of water were observed. There is also an Additional Dwelling Unit behind the facility with a separate entrance.
Bedrooms Residents- Rooms #1 and #5 may be used for Non-Ambulatory; Rooms #2-#4 ambulatory use.
Bedrooms Staff- Room #3 is for staff use only.
Bathrooms- All bathrooms have a working toilet, sink, grab bars and tub/showers with non-skid mats.
Linens & Hygiene Supplies- Adequate supply.
Emergency Phone Numbers, Exit Plan and Required Postings- Posted.
Smoke Detectors and Carbon Monoxide Detectors- Interconnected and hardwired.
Appliances- Stove burners, oven, microwave, washer, and dryer working.
Toxins- Stored in a locked cabinet.
Water Temperature- Measured at 117 degrees F.
Medications- Centrally stored and locked in a cabinet.
First-Aid Kit- Stored in a locked cabinet.
Resident & Staff Files- Stored in locked cabinet.
Activities- Adequate supplies board games, puzzles, and magazine's for resident's use.
Fire clearance- Approved on 09/23/24.

Component III- Conducted at the Pre-Licensing visit. Information provided about how to operate the facility within substantial compliance.



All items reviewed during the visit are in compliance. Prelicensing is complete and this facility has no deficiencies. Facility appears to be ready for licensure pending final review. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Applicant, Josephine Tayaba whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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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