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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604857
Report Date: 02/05/2025
Date Signed: 02/05/2025 12:54:07 PM

Document Has Been Signed on 02/05/2025 12:54 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:COLLEGE TOWN SENIOR RETIREMENT VILLA IFACILITY NUMBER:
374604857
ADMINISTRATOR/
DIRECTOR:
MOLINA, STEPHANIEFACILITY TYPE:
740
ADDRESS:5244 STONE COURTTELEPHONE:
(818) 284-2502
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY: 6CENSUS: 0DATE:
02/05/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Applicant Anna Petrosyan and Administrator Stephanie MolinaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPAs) Amy Rodgers , Angelica Boyles, Arian Golbakhsh conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code. LPA was greeted by, identified themselves to, and explained the purpose of the visit to Applicant Anna Petrosyan Administrator Stephanie Molina.

The facility fire clearance was granted on October 17, 2024 and reflects that the facility is approved for 6 residents, and that all 6 can be non-ambulatory.

During today’s visit, LPA, accompanied by the applicant, 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 and showers were in working order. The facility’s ambient internal temperature compliant .Water temperatures at taps for resident use were compliant. The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for future resident use.

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 client 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 clients. Per the applicant, no firearms or ammunition are or will be stored at the facility.


[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: COLLEGE TOWN SENIOR RETIREMENT VILLA I
FACILITY NUMBER: 374604857
VISIT DATE: 02/05/2025
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[CONTINUED FROM LIC809]

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. 1 fire extinguisher and 1 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, Chapter 8 of California Code of Regulations and Health & Safety Code. The applicant passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit.

Petrosyan and Molina were advised that the facility’s application is pending management final review and approval. An exit interview was conducted with the applicant and administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided at time of the visit.

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SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
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