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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804865
Report Date: 11/25/2020
Date Signed: 11/25/2020 03:58:07 PM

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:CARROLLS RESIDENTIAL CAREFACILITY NUMBER:
370804865
ADMINISTRATOR:BRYAN MEYERSFACILITY TYPE:
740
ADDRESS:655 S MOLLISONTELEPHONE:
(619) 444-3181
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:144CENSUS: 117DATE:
11/25/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Pamela Pineiro, Assistant AdministratorTIME COMPLETED:
12:35 PM
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Licensing Program Manager (LPM), Denise Powell, County of San Diego Nurse Contractors, Jennifer West and Sandra Brockman; California Department Public Health (CDPH), Health Facility Evaluator Nurse (HFEN), Denise Elliott with the HAI Program, conducted an on-site visit. LPM and team identified themselves and discussed the purpose of the visit with Administrator Brian Meyers and Assistant Administrator Pamela Pineiro.

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 Administrator Meyers and Ms.Pineiro and conducted a walk-though of the facility. A debriefing was conducted with Ms. Pineiro at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with the Assistant Administrator and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to her and facility Administrator via electronic mail. An electronic receipt of confirmation was requested to be sent by facility representative upon receipt of the documents.
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Denise PowellTELEPHONE: 619-301-9770
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
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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