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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808315
Report Date: 06/10/2022
Date Signed: 06/10/2022 11:18:33 AM

Document Has Been Signed on 06/10/2022 11:18 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:VELASCO HOME IIFACILITY NUMBER:
370808315
ADMINISTRATOR:ELIZABETH VELASCOFACILITY TYPE:
735
ADDRESS:1537 LARKHAVEN DRIVETELEPHONE:
(619) 585-1283
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 5DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Marites Chiapoco, CaregiverTIME COMPLETED:
11:30 AM
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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 Teresa Legaspi, caregiver. LPA met with caregiver Marites Chiapoco and discussed the purpose of today’s visit.

A tour of the facility was conducted inside and out. LPA accompanied by caregiver Chiapoco 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/hand hygiene practices, cough and sneeze etiquette and other infection control procedures; testing plan and procedures for staff and clients; plans for containing infections; PPE supplies procedures and training; and disinfection procedures.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with caregiver Chiapoco. A copy of this report, along with the Licensee Rights (01/2016) was provided to caregiver Chiapoco at the conclusion of the visit. The signature below serves as confirmation of receipt of these documents.

LPA requested for caregiver Chiapoco to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-D to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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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