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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601258
Report Date: 10/04/2021
Date Signed: 10/04/2021 05:29:08 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:FAIRWINDS - IVEY RANCHFACILITY NUMBER:
374601258
ADMINISTRATOR:SOMMER, JESSICAFACILITY TYPE:
740
ADDRESS:4490 MESA DRTELEPHONE:
(760) 439-8090
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:200CENSUS: 143DATE:
10/04/2021
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Jessica SommerTIME COMPLETED:
11:37 AM
NARRATIVE
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Licensing Program Analyst, Kristina Ryan, and County of San Diego Nurse HAI Site Assessment Contractors, Sandra Brackman, and Elizar Perez conducted an on-site visit. The team identified themselves and discussed the purpose of the visit with Administrator, Jessica Sommer.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment. During today's visit, the team interviewed Ms. Sommer and conducted a walk-through of the facility. A debriefing was conducted with Ms. Sommer at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with Ms. Sommer and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to Ms. Sommer, via electronic mail. An electronic receipt confirms receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
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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