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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808112
Report Date: 12/13/2021
Date Signed: 12/13/2021 01:59:13 PM

Document Has Been Signed on 12/13/2021 01:59 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:FANCOR GUEST HOMEFACILITY NUMBER:
370808112
ADMINISTRATOR:HUERTAS, FANNIEFACILITY TYPE:
735
ADDRESS:631-651 TAFT AVENUETELEPHONE:
(619) 588-1761
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY: 44CENSUS: 42DATE:
12/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Assistant Administrator, Myra PalmerTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Lizzette Tellez, and County of San Diego Public Health Nurses, Jennifer West and Sandy Brackman with the Healthcare-Associated Infections (HAI) Program, conducted an on-site HAI assessment visit. LPA and team identified themselves and discussed the purpose of the visit with Assistant Administrator, Myra Palmer.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan to include disinfection, testing, vaccination, and screening protocols as well as the use of personal protective equipment (PPE). During today's visit, LPA and team conducted a walk-though of the facility. A debriefing was conducted with Ms. Palmer at the conclusion of the visit.

No deficiencies were cited during today's visit. An exit interview was conducted with Ms. Palmer, and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Lizzette Tellez
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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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