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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004630
Report Date: 08/11/2022
Date Signed: 08/11/2022 10:12:04 AM


Document Has Been Signed on 08/11/2022 10:12 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:COUNTRY CLUB GUEST HOMEFACILITY NUMBER:
372004630
ADMINISTRATOR:RAMIREZ, JULIEFACILITY TYPE:
740
ADDRESS:25533 RUA MICHELLETELEPHONE:
(760) 747-0957
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:30CENSUS: 28DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kevin Ramirez, Asst. AdministratorTIME COMPLETED:
10:20 AM
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) Tricia Danielson arrived unannounced to the facility to conduct an annual inspection with emphasis on infection control. LPA met with Assistant Administrator Kevin Ramirez and explained the purpose of today’s visit. The facility has submitted an Infection Control Plan as required.

During the inspection, LPA interviewed Ramirez regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed appropriate postings at the facility front entrance, including COVID-19 symptoms postings, which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA observed facility staff wearing appropriate face coverings. The facility has a designated infection control lead person/infection preventionist who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring staff are trained in the facility's infection control procedures, and ensuring infection control measures are implemented. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for residents and staff with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician, emergency personnel, and responsible party in the event the resident presents with any COVID-19 symptoms.

No deficiencies were observed during today's visit. An exit interview was conducted, and a copy of this report was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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