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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601560
Report Date: 01/30/2023
Date Signed: 01/30/2023 11:19:42 AM


Document Has Been Signed on 01/30/2023 11:19 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:GLENBROOK ASSISTED LIVINGFACILITY NUMBER:
374601560
ADMINISTRATOR:HARNESS, SADIEFACILITY TYPE:
740
ADDRESS:1950 CALLE BARCELONATELEPHONE:
(760) 704-6800
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:95CENSUS: 60DATE:
01/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Director Kahina HadibiTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Tammer de los Santos visited the facility to conduct an annual required licensing inspection. LPA was granted entry into the facility by Director Kahina Hadibi to whom LPA disclosed the purpose of the visit.

During today's visit, LPA toured the facility and verified compliance with infection control practices. LPA observed one central entry point for universal entry screening; a sign-in policy enacted for visitors; signs in the facility to promote hand hygiene, cough / sneeze etiquette, symptom, and transmission awareness; face coverings worn by staff; hand sanitizer readily available; an available visitation area.

Director previously provided a copy of the completed Infection Control Plan.

No deficiencies were cited during today’s visit. An exit interview was conducted with Director Kahina Hadibi, and copies of this report and Licensee Rights (LIC 9058) were provided at the conclusion of the visit. Facility representative’s signature on this form acknowledges receipt of the rights and a copy of the report.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Tammer DeLosSantosTELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
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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