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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600411
Report Date: 07/27/2022
Date Signed: 07/27/2022 03:39:14 PM


Document Has Been Signed on 07/27/2022 03:39 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:MISSION HOME IIFACILITY NUMBER:
374600411
ADMINISTRATOR:JOHN CURMAKFACILITY TYPE:
740
ADDRESS:2997 MELBOURNE DRIVETELEPHONE:
(858) 569-4028
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY:6CENSUS: 6DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Caregiver, Nora Rivera and Administrator, Ceren CurmakTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Daniel Pena visited the facility and conducted an unannounced Required 1 - Year inspection. The facility file was reviewed prior to the visit. LPA was greeted by, identified himself to, and explained the purpose of the visit to Caregiver, Nora Rivera. Staff, Carla Gonzalez was also present. LPA was granted entry into the facility. Administrator, Ceren Curmak later arrived during the inspection for a brief period. LPA verified that all staff present have a current criminal record clearance.

During today's visit, LPA toured the facility and verified compliance with infection control practices. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, clients and visitors and a sign-in policy enacted for visitors. Infection control related signs to promote hand hygiene, cough/sneeze etiquette, symptom and transmission awareness were observed. Staff wore face coverings and hand sanitizer/hand washing stations were readily available. LPA observed an available visitation area and the facility had an ample supply of cleaning products and PPE. LPA provided guidance and PIN 21-38-ASC as it pertains to N-95 respirator fit-test requirements for staff.

No deficiencies were cited during today’s visit. An exit interview was conducted with Caregiver, Rivera and a copy of this report and Licensee Rights (LIC 9058 FAS 01/16) was provided at the facility.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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