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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808482
Report Date: 01/03/2022
Date Signed: 01/03/2022 08:34:58 PM

Document Has Been Signed on 01/03/2022 08:34 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:DSC - VILLAGE HOUSEFACILITY NUMBER:
370808482
ADMINISTRATOR:KRISTEN HOLLOBAUGHFACILITY TYPE:
735
ADDRESS:6010 HOWELLTELEPHONE:
(619) 697-1611
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY: 6CENSUS: 5DATE:
01/03/2022
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Patricia Barber and Administrator Kristen HollobaughTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Case Management visit, accompanied by nurse contractor Sandra Brackman from the Healthcare Associated Infection (HAI) team of San Diego County Health and Human Services Agency. LPA and HAI nurse were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Patricia Barber and Administrator Kristen Hollobaugh.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's COVID-19 screening, testing, and disinfection processes and the staff’s use of personal protective equipment. During the visit, LPA and HAI nurse briefly toured the facility, interacted with staff, and observed the clients in care. No deficiencies were cited on this date.

An exit interview was conducted with Barber, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2022
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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