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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600860
Report Date: 10/14/2021
Date Signed: 10/14/2021 02:39:05 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:PINE VALLEY HOME CAREFACILITY NUMBER:
374600860
ADMINISTRATOR:DOMILOS, NORISAFACILITY TYPE:
740
ADDRESS:1530 MONTE VISTA DRIVETELEPHONE:
(760) 630-6381
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 2DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Norisa Domilos, LicenseeTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself and was granted entry by Ruth Aglasi, House Manager. LPA met with Ruth Aglasi and discussed the purpose of today’s visit. Licensee Norisa Domilos later arrived.

A tour of the facility was conducted inside and out. LPA, accompanied by Licensee Norisa Domilos and House Manager Ruth Aglasi, conducted a general overall inspection, with specific focus on infection control protocols.

During today's inspection LPA observations include the following: Symptom screening procedures/ for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; Hand hygiene practices; testing plan and procedures; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Licensee Norisa Domilos. A copy of this report, along with the Licensee Rights (01/2016) was emailed to Licensee at the conclusion of the visit. LPA requested Licensee to send LPA an electronic message reply confirming receipt of these documents.

LPA requested Licensee Domilos to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-E to the licensing office within 10 business days. Forms available at www.ccld.ca.gov.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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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