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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804527
Report Date: 07/14/2022
Date Signed: 07/14/2022 03:32:37 PM


Document Has Been Signed on 07/14/2022 03:32 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:LIWAG'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
370804527
ADMINISTRATOR:NORA B. LIWAGFACILITY TYPE:
740
ADDRESS:3993 CASEMAN STREETTELEPHONE:
(619) 690-1022
CITY:SAN DIEGOSTATE: CAZIP CODE:
92154
CAPACITY:6CENSUS: 5DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Nora B. Liwag, LicenseeTIME COMPLETED:
11:27 AM
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Licensing Program Analyst, Amy Domingo, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Nora Liwag (Licensee) and we discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPA conducted a tour of the facility, both inside and outside and observed the residents in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.

No deficiencies were cited or observed on this date. The Licensee was provided a copy of her appeal rights (LIC9058 01/16), and her signature on this form, acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided to Nora Liwag.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
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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