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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004808
Report Date: 05/16/2022
Date Signed: 05/17/2022 08:08:19 AM


Document Has Been Signed on 05/17/2022 08:08 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:MISSION HOMEFACILITY NUMBER:
372004808
ADMINISTRATOR:JOHN CURMAKFACILITY TYPE:
740
ADDRESS:2996 MISSION VILLAGE DR.TELEPHONE:
(858) 569-8867
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY:6CENSUS: 6DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:House Manager, Gunnur CermakTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Kayla Hilario, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with House Manager, Gunnur Cermak and identified herself and discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPA conducted a tour of the facility, both inside and outside and observed the residents in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.

No deficiencies were cited or observed on this date.

An exit interview was conducted with House Manager, Gunnur Cermak. A copy of this report and Licensee's Rights (LIC 9058 01/16) were provided to the House Manger via hard copy at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
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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