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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600808
Report Date: 06/11/2021
Date Signed: 06/11/2021 12:58:00 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:MELROSE CARE HOME IIFACILITY NUMBER:
374600808
ADMINISTRATOR:LILIA P. RENAFACILITY TYPE:
740
ADDRESS:1627 MARL AVENUETELEPHONE:
(619) 498-0911
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY:6CENSUS: 5DATE:
06/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Licensee, Lilia Rena TIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an annual required licensing inspection. This annual inspection was focused on infection control due to the COVID-19 pandemic. LPA was greeted at the front door by Caregiver, Delia Perez and granted entry after identifying herself. LPA discussed the purpose of the visit with Licensee, Lilia Rena. This facility serves six (6) residents aged 60 and over; all of whom may be non-ambulatory.

During today's visit, LPA toured the facility with Licensee Lilia Rena and verified compliance with infection control practices. LPA and Licensee reviewed the facility’s COVID-19 Mitigation Plan Report. LPA observed one central entry point; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs throughout the facility to promote hand hygiene and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of PPE and disinfectants. LPA discussed the Provider Information Notices (PINs) regarding updated guidance on visitation.

Based on today's visit, no deficiencies were observed at this time in the areas evaluated above. An exit interview was conducted with Lilia Rena and a copy of this report along with the Licensee/Appeal Rights (LIC 9058) was provided via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
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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