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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804859
Report Date: 03/07/2022
Date Signed: 03/07/2022 01:55:59 PM


Document Has Been Signed on 03/07/2022 01:55 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:TESSIE BOARD AND CAREFACILITY NUMBER:
370804859
ADMINISTRATOR:PEDROSO, TERESITAFACILITY TYPE:
740
ADDRESS:7229 ZEST STREETTELEPHONE:
(619) 773-6360
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY:5CENSUS: 5DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Teresita Pedroso, LicenseeTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself and was granted entry by Teresita Pedroso, Licensee. LPA met with Licensee Pedroso and discussed the purpose of today’s visit.

A tour of the facility was conducted inside and out. LPA, accompanied by Licensee Pedroso conducted a general overall inspection, with specific focus on infection control protocols.

During today's inspection LPA observations include the following: Symptom screening procedures/ for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; Hand hygiene practices; testing plan and procedures; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.

Based on today’s inspection, no deficiencies were cited. An exit interview was conducted with Licensee Pedroso. A copy of this report, along with the Licensee Rights (01/2016) was emailed to Teresita Pedroso, Licensee, at the conclusion of the visit. LPA requested for Licensee Pedroso to send LPA an electronic message reply confirming receipt of these documents.

LPA requested Licensee Pedroso to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-E to the licensing office within 10 business days. Forms available at www.ccld.ca.gov.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
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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