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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372000641
Report Date: 08/19/2021
Date Signed: 08/19/2021 01:43:42 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:WHITE SANDS LA JOLLAFACILITY NUMBER:
372000641
ADMINISTRATOR:BORIERO, GARYFACILITY TYPE:
741
ADDRESS:7450 OLIVETAS AVETELEPHONE:
(858) 454-4201
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:299CENSUS: DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Shelly Smart, Health Services AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Laarni Santiago conducted an unannounced annual required licensing inspection. LPA was granted entry by Health Services Administrator, Shelly Smart after identifying herself and disclosing the purpose of the visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with infection control practices.

A facility tour was conducted with Health Service Administrator, Shelly Smart. LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Infection Control with the Administrator including the following sections: Persons in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility's Plans for Infection Control and Physical Distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety.

LPA reviewed items pertaining to central entry points for universal entry screening; routine symptom screening initiated for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and clients; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE.

No deficiencies were cited during today's visit.

An exit interview was conducted with the Health Services Administrator. A copy of this report, along with the Licensee Rights (9058 01/16) were provided to Health Services Administrator, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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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