<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601317
Report Date: 08/25/2021
Date Signed: 08/25/2021 03:04:29 PM

Document Has Been Signed on 08/25/2021 03:04 PM - 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:CHATEAU ST. MARK HOMES 5 / PLAYA DEL REY HOUSEFACILITY NUMBER:
374601317
ADMINISTRATOR:MARTIN LOPEZFACILITY TYPE:
735
ADDRESS:105 PLAYA DEL REYTELEPHONE:
(760) 696-3777
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY: 4CENSUS: 3DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Caregiver, Marissa Pornel and Caregiver, Yolanda DizonTIME COMPLETED:
11:25 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an annual required licensing inspection. This annual inspection was focused on infection control due to the COVID-19 pandemic. LPA was greeted at the front door by Caregiver, Marrisa Pornel and granted entry after identifying herself. LPA Hamilton explained the purpose of the visit with Caregivers, Marrisa Pornel and Yolanda Dizon. This facility serves four (4) clients age 18-59; all of whom may be non-ambulatory.

During today's visit, LPA toured the facility, and verified compliance with infection control practices. LPA and Caregivers, Pornel and Dizon reviewed the facility’s COVID-19 Mitigation Plan. LPA observed one central entry point; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs throughout the facility to promote hand hygiene, face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of PPE and disinfectants. LPA discussed the Provider Information Notice (PIN) regarding updated guidance on visitation and moving the universal screening to the front door.

Based on today's visit, no deficiencies were observed in the areas evaluated above. An exit interview was conducted with Caregivers Pornel and Dizon and a copy of this report along with the Licensee/Appeal Rights (LIC 9058) was provided via email. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1