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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600808
Report Date: 07/13/2022
Date Signed: 07/13/2022 11:56:53 AM


Document Has Been Signed on 07/13/2022 11:56 AM - 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: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: 4DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Licensee, Lilia RenaTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced annual required licensing inspection. LPA was granted entry by Licensee, Lilia Rena and was granted entry after identifying herself and disclosing the purpose of the visit. An overall tour of the facility was conducted. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Licensee, Rena including the following sections: Person in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility has Plans for Infection Control and Physical Distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety.

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 were provided to be posted 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 PPE. The facility in in compliance with and has implemented infection control practices as outlined in its LIC 808.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Licensee Rena. A copy of this report, along with the Licensee Rights (9058 01/16) was printed and provided to Licensee at the facility.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
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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