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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370803020
Report Date: 04/20/2022
Date Signed: 04/20/2022 04:42:16 PM

Document Has Been Signed on 04/20/2022 04:42 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:BAUM FAMILY CARE HOMEFACILITY NUMBER:
370803020
ADMINISTRATOR:BAUM, RONALD&CHERYLFACILITY TYPE:
735
ADDRESS:9627 RANCHO MIRAGE LANETELEPHONE:
(619) 390-8978
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 6CENSUS: 6DATE:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Direct Support Professional (DSP) Carrie BaumTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an annual required licensing inspection. LPA Correia was met by Direct Support Professional (DSP) Carrie Baum, identified herself, and explained the purpose of the visit.

During today's visit, LPA Correia, accompanied by DSP Baum, toured the facility and verified compliance with infection control practices. LPA Correia and DSP Baum reviewed the facility’s Plan for Epidemic Outbreak Specific to the COVID-19 Mitigation Plan Report. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents, and visitors; tracking of vaccination status or COVID-19 test results and a sign-in policy enacted for all visitors. Facility maintains documentation of visitor, staff, and resident vaccination records. LPA Correia observed infection control signs posted at the facility entrance, as well as posted throughout the facility to promote infection control/universal precautions. Also observed were hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an ample supply of disinfectant products and PPE.

No deficiencies were cited during today’s visit. An exit interview was conducted with DSP Baum, and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to her via email. An electronic receipt of confirmation was requested to be sent by DSP Baum upon receipt of the documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
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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