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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370803192
Report Date: 08/17/2021
Date Signed: 08/17/2021 01:38:49 PM

Document Has Been Signed on 08/17/2021 01:38 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:ARC OF SAN DIEGO-SOL AND RUTH GERBER FAMILY CENTERFACILITY NUMBER:
370803192
ADMINISTRATOR:LILIANA DOLBAIAFACILITY TYPE:
775
ADDRESS:1280 NOLAN AVENUETELEPHONE:
(619) 427-7524
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 186CENSUS: 23DATE:
08/17/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Program Administrator, Susana Levack and Senior Director of Adult Day Services, Melanie McCoyTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA), Elizabeth Hamilton, County of San Diego Nurse Contractors, Sandra Brackman, and Robert Montillano conducted an on-site visit. The team identified themselves and discussed the purpose of the visit with Program Administrator, Susana Levack and Senior Director of Adult Day Services, Melanie McCoy.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment. During today's visit, the team interviewed Levack and McCoy and conducted a walk-through of the facility. A debriefing was conducted with Levack and McCoy at the conclusion of the visit.

During today's visit, no deficiencies were observed. An exit interview was conducted with Levack and McCoy and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to Program Administrator via electronic mail. An electronic receipt was requested to confirm receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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