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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600950
Report Date: 07/19/2022
Date Signed: 08/01/2022 09:39:23 AM


Document Has Been Signed on 08/01/2022 09:39 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:GOOD SAMARITAN RETIREMENT HOMEFACILITY NUMBER:
374600950
ADMINISTRATOR:SUSAN SORENSENFACILITY TYPE:
740
ADDRESS:1515 JAMACHA WAYTELEPHONE:
(619) 590-1515
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:70CENSUS: 49DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Office Manager Vicky MammoTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Kayla Hilario, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA identified herself, disclosed the purpose of the visit, and met with Office Manager Vicky Mammo and Nurse Cristina Robinson Senescall. All staff present have a current criminal record clearance. Administrator Susan Sorensen joined via telephone.

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, 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 or observed on this date.

An exit interview was conducted with Office Manager Vicky Mammo. A copy of this report and appeal rights (LIC9056 01/16), were provided via hardcopy at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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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