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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601334
Report Date: 04/13/2022
Date Signed: 05/24/2022 08:23:08 AM


Document Has Been Signed on 05/24/2022 08:23 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:SERRA MESA GUESTS HOME III, LLCFACILITY NUMBER:
374601334
ADMINISTRATOR:SALAZAR, EVELYNFACILITY TYPE:
740
ADDRESS:3008 MELBOURNE DRTELEPHONE:
(858) 277-6515
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY:6CENSUS: 5DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Caregiver Joy SingsonTIME COMPLETED:
11:00 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 met with Caregiver Joy Singson and we discussed the purpose of the visit. All staff present have a current criminal record clearance. Administrator Evelyn Salazar arrived during the visit.

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 Caregiver Joy Singson. A copy of this report and appeal rights (LIC9056 01/16), were provided to the Caregiver 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: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022
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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