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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601276
Report Date: 04/22/2022
Date Signed: 04/25/2022 04:45:24 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/25/2022 04:45 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:ANGEL'S GUEST HOME #1FACILITY NUMBER:
374601276
ADMINISTRATOR:JENKINS, PATRICIAFACILITY TYPE:
740
ADDRESS:9208 BELLAGIO RDTELEPHONE:
(619) 258-2013
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY:6CENSUS: 5DATE:
04/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee Cathy McEvoyTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced annual required licensing inspection. LPA Correia identified herself, was granted entrance into the facility, and met with Licensee Cathy McEvoy. 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 in the area of infection control practices

LPA and Licensee reviewed the facility’s Plan for Epidemic Outbreak Specific to the COVID-19 Mitigation Plan Report (LIC 808), including the following sections: Person in Care, Staff, Visitors, Facility implementation for infection control and physical distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, the implementation of infection control guidance, staff retention, and essential health and safety as outlined in the facility's Mitigation Plan Report (LIC 808). LPA and Licensee McEvoy also reviewed the new requirements per Provider Information Notification (PIN) 22-13-ASC.

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 posted throughout the facility to promote hand hygiene; cough/sneeze etiquette and physical distancing; face coverings; signs posted at facility entrance with the facility’s visitor policy will be updated; 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 is in compliance with and has implemented infection control practices as outlined in its LIC 808.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ANGEL'S GUEST HOME #1
FACILITY NUMBER: 374601276
VISIT DATE: 04/22/2022
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Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Licensee McEvoy. A copy of this report, along with the Licensee Rights (9058 01/16) was emailed to the Licensee at the conclusion of the visit, an electronic response confirms the receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC809 (FAS) - (06/04)
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