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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808298
Report Date: 03/14/2022
Date Signed: 03/16/2022 06:19:56 AM

Document Has Been Signed on 03/16/2022 06:19 AM - 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:JACKIE'S BOARD AND CAREFACILITY NUMBER:
370808298
ADMINISTRATOR:JACKIE CUNNINGHAMFACILITY TYPE:
735
ADDRESS:10863 EL NOPALTELEPHONE:
(619) 258-7390
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY: 6CENSUS: 6DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee Jackie CunninghamTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Debbie Correia visited the facility to conduct an annual required licensing inspection. LPA Correia was met by Licensee Jackie Cunningham, identified herself, and was granted entry into the facility.

During today's visit, LPA, accompanied by Licensee Cunningham, toured the facility and verified compliance with infection control practices. LPA and Licensee Cunningham, the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, clients and visitors; a sign-in policy enacted for all visitors; signs posted throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; emergency agencies’ contact information posted in a location visible to staff and clients; and an adequate supply of cleaning products and PPE.

No deficiencies were cited during today’s visit. An exit interview was conducted with Licensee Cunningham, and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to her via email. An electronic receipt of confirmation was requested to be sent by Licensee Cunningham upon receipt of the documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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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