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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372008467
Report Date: 02/17/2022
Date Signed: 02/18/2022 07:46:38 AM

Document Has Been Signed on 02/18/2022 07:46 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:DOWNSTOWN IVFACILITY NUMBER:
372008467
ADMINISTRATOR:SUSAN LAUBACHFACILITY TYPE:
735
ADDRESS:1710 REES ROADTELEPHONE:
(760) 746-2111
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 6CENSUS: 3DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Administrator Elisa Ciaverelli and Staff Dannielle ElliottTIME COMPLETED:
11:50 AM
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On 2/17/22, at 10:33 a.m., Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required 1 - Year Visit. LPA Martinez was greeted by Staff, Danielle Elliott, identified himself, and discussed the purpose of the visit. Administrator, Elisa Ciaverelli, arrived during the visit.

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

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, cough/sneeze etiquette and physical distancing; 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; and an adequate supply of PPE (Personal Protective Equipment). 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 Staff, Danielle Elliott, and Administrator, Elisa Ciaverelli. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail to Assistant Executive Director, Susan Laubach. A read receipt email confirms the receipt of these documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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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