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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600708
Report Date: 11/10/2021
Date Signed: 11/11/2021 10:24:23 AM

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:LILAC CHATEAU IIFACILITY NUMBER:
374600708
ADMINISTRATOR:KIMBERLY WITHERSFACILITY TYPE:
740
ADDRESS:9724 EUCALYPTUS COURTTELEPHONE:
(619) 449-6187
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY:6CENSUS: 3DATE:
11/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee, Kimberly WithersTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Correia visited the facility to conduct an annual required licensing inspection. LPA identified herself, was granted entry into the facility and met with Licensee Kimberly Withers, with whom she discussed the purpose of the visit.

During today's visit, LPA toured the facility to verify compliance with infection control practices. LPA and facility staff reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation. LPA observed one central entry point for universal entry screening; including temperature and symptoms checks, a questionnaire regarding possible exposure, and vaccination and/or test result checks for staff, residents and visitors. Signs in the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; hand sanitizer/hand washing stations readily available; available visitation areas; emergency agencies’ and emergency contact information are all up to date and readily available. LPA observed an adequate supply of cleaning products and PPE supplies at the facility.

No deficiencies were cited during today’s visit. An exit interview was conducted with Licensee Withers, and a copy of this report and Licensee Rights (LIC 9058, FAS 01/16) were provided to Licensee Withers via email following the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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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