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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800394
Report Date: 10/14/2021
Date Signed: 10/14/2021 04:10:50 PM

Document Has Been Signed on 10/14/2021 04:10 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:COVENANT LIVING AT MOUNT MIGUELFACILITY NUMBER:
370800394
ADMINISTRATOR:RICHARD MILLERFACILITY TYPE:
741
ADDRESS:325 KEMPTON STREETTELEPHONE:
(619) 479-4790
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 434CENSUS: 309DATE:
10/14/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Ron Alamario, Assisted Living
Director		TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA), Tiffany Holmes conducted an unannounced case management visit. LPA Holmes introduced herself and was allowed entry into the facility and explained the purpose of the visit to Ron Alamario, Assisted Living
Director.

Today’s visit was regarding resident health checks. During today’s visit LPA interviewed staff and requested copies of facility records and toured the facility. The department is following up on two death reports that were provided to the department.

Based on today's inspection, no deficiencies were observed.

An exit interview was conducted with Ron Alamario, Assisted Living Director. A copy of this report, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail. An electronic read receipt verifies receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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