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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604892
Report Date: 03/14/2025
Date Signed: 03/14/2025 03:12:53 PM

Document Has Been Signed on 03/14/2025 03:12 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:MELROSE 30FACILITY NUMBER:
374604892
ADMINISTRATOR/
DIRECTOR:		SONGCO, ARCELIFACILITY TYPE:
740
ADDRESS:14530 GARDEN RDTELEPHONE:
(702) 776-0689
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 0DATE:
03/14/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jushua "Justin" Mendoza, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA), Amy Rodgers conducted an announced Pre-licensing inspection. An initial application to operate a Residential Care Facility for the Elderly was received on 1/24/2025. The facility was approved to care for six (6) Elderly Residents; of which six (6) are Non-Ambulatory.LPA was greeted by, identified herself to, and explained the purpose of the visit to the applicant’s representative, Justin Mendoza.

Structure- The facility is a single story structure with 6 bedrooms and 5 bathrooms. There is an outdoor covered area for resident use. No bodies of water were observed.


Bedrooms Residents- Rooms #1, #2, #3, #4, #5 & #6 for Non-Ambulatory use.
Bathrooms- All bathrooms have a working toilet, sink, grab bars and tub/showers with non-skid mats.
Linens & Hygiene Supplies- Adequate supply in the hall storage closet..
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 and locked under the sink in cabinet.
Water Temperature- Measured compliant in the all facets accessible to clients: bathrooms and kitchen.
Medications- Centrally stored and locked in a cabinet in the kitchen..
First-Aid Kit- Stored in a locked cabinet in the kitchen
Resident & Staff Files- Stored in a locked cabinet in the kitchen.
Activities- Adequate supplies to include exercising, and games for resident's use are stored on campus.
Fire clearance- Approved on 1/24/25. 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. Pre-licensing 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 Justin Mendoza Administrator signature below confirms receipt of these rights.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
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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