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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604885
Report Date: 03/10/2025
Date Signed: 03/10/2025 01:29:38 PM

Document Has Been Signed on 03/10/2025 01:29 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:AGING GRACEFULLY CARE HOMES LLCFACILITY NUMBER:
374604885
ADMINISTRATOR/
DIRECTOR:		PALAD, IRENEFACILITY TYPE:
740
ADDRESS:3218 MIRA MESA AVENUETELEPHONE:
(760) 207-6488
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY: 6CENSUS: 5DATE:
03/10/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Applicant Irene PaladTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an announced Pre-Licensing visit. LPA was met by Applicant Irene Palad and was granted entry into the facility. The purpose of today's visit is to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The fire inspection was completed on 11/12/2024 and the facility is approved for 6 non-ambulatory residents. The facility has two staff bedrooms on the second floor of the building.

During today's visit, LPA toured the facility and inspected every room. The facility was found to be clean, safe, and in good repair with no pathway obstructions. Private and common bathrooms were observed to be clean and the toilets and showers were found to be in working order. The facility's water temperature in bathrooms for resident and staff use were measured at 119.5 and 105.4 degrees Fahrenheit. LPA observed locked storage areas where all hazardous and/or toxic chemicals were stored and secured. LPA observed locked storage for resident medications. Fire extinguishers were observed throughout the facility and found to be in compliance. A functioning carbon monoxide detector and smoke detectors were observed in the facility. No bodies of water were observed near or on the premises. LPA observed a 7-day supply of non-perishable food and a 2-day supply of perishable food. Required postings were observed in a common area of the facility. LPA reviewed facility’s Infection Control Plan and Emergency Disaster Plan.

LPA conducted Component III with the applicant. The topics discussed were continuing operation requirements, record keeping/reporting, and physical plant compliance.

Pre-licensing is complete, and this facility has no deficiencies. It is recommended that this facility be licensed pending final review and approval. An exit interview was conducted with the applicant, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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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