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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600688
Report Date: 09/27/2021
Date Signed: 09/27/2021 02:00:51 PM

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:FAMILY-STYLE CARE IIFACILITY NUMBER:
374600688
ADMINISTRATOR:LUZVIMINDA CRISOSTOMOFACILITY TYPE:
740
ADDRESS:2847 MORNINGSIDE STREETTELEPHONE:
(619) 434-6782
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY:6CENSUS: 6DATE:
09/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator, Kimberly GonzalezTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Lizzette Tellez visited the facility to conduct an annual required licensing inspection. LPA was met by Caregiver, Teresita Montemayor, and was granted entry into the facility. LPA met with Administrator, Kimberly Gonzalez, and discussed the purpose of the visit.

During today's visit, LPA toured the facility, and verified compliance with infection control practices. LPA and Ms. Gonzalez reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents 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 cleaning products and PPE.

No deficiencies were cited during today’s visit. An exit interview was conducted with Ms. Gonzalez, and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to them via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
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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