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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004561
Report Date: 09/07/2022
Date Signed: 09/07/2022 03:21:59 PM


Document Has Been Signed on 09/07/2022 03:21 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:MAILE ALOHAFACILITY NUMBER:
372004561
ADMINISTRATOR:PEREZ, JOSEPHINE A.FACILITY TYPE:
740
ADDRESS:3636 CHRISTINE STREETTELEPHONE:
(858) 274-0921
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:12CENSUS: 8DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Licensee, Josephine Perez, and Staff, Orlando PerezTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced Required 1 - Year Visit. The LPA introduced himself, was greeted by Licensee, Josephine Perez, and Staff, Orlando Perez, and discussed the purpose of the visit.

The LPA conducted a tour with the licensee. In accordance with the Department’s Infection Control program, The LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

During today's visit the, the LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff 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; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents. Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit.

An exit interview was conducted with Licensee, Josephine Perez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided to.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
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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