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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600732
Report Date: 05/24/2022
Date Signed: 05/24/2022 01:50:50 PM


Document Has Been Signed on 05/24/2022 01:50 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:CARMONA'S RESIDENTIAL CAREFACILITY NUMBER:
374600732
ADMINISTRATOR:MARY ANNE MARTINEZFACILITY TYPE:
740
ADDRESS:3427 BEAGLE PLACETELEPHONE:
(858) 277-6731
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY:6CENSUS: 5DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Leonora Baquiran LicenseeTIME COMPLETED:
01:49 PM
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Licensing Program Manager (LPM) Denise Powell and Licensing Program Analyst Amy Domingo conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPM and LPA met with and were allowed entry by caregiver Milagraos Caganap and we discussed the purpose of the visit. Licensee Leonor Carmona arrived during the visit. All staff present have a current criminal record clearance.

LPM and 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, LPM and 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 on this date.

LPA provided additional guidance on posting signs regarding infection control, hand washing, cough etiquette. Also informed Leonora of the Provider Information call that is up coming and availability of PPE.

An exit interview was conducted with the licensee, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.

SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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