<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372000400
Report Date: 12/09/2021
Date Signed: 12/09/2021 03:47:52 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:NAZARETH HOUSEFACILITY NUMBER:
372000400
ADMINISTRATOR:PETROSYAN, MILENAFACILITY TYPE:
740
ADDRESS:6333 RANCHO MISSION ROADTELEPHONE:
(619) 563-0480
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:145CENSUS: 88DATE:
12/09/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Milena PetrosyanTIME COMPLETED:
02:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Rebecca Ruiz and County of San Diego Nurse Contractors, Sandra Brackman and Jennifer West with the HAI Program, conducted an on-site HAI assessment visit. LPA and team identified themselves and discussed the purpose of the visit with Executive Director Milena Petrosyan and Chief Executive Officer Barbara-Ann Crowley.

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, the team interviewed the Executive Director and Chief Executive Director and conducted a walk-though of the facility. A debriefing was conducted at the conclusion of the visit.

During today's visit, no deficiencies were cited. An exit interview was conducted with the Executive Director Milena Petrosyan and Chief Executive Officer Barbara-Ann Crowley. A copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to Milena Petrosyan via electronic mail. An electronic receipt of confirmation was requested upon receipt of the documents.
SUPERVISOR'S NAME: Alexandre VoTELEPHONE: (619) 385-7506
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1