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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601767
Report Date: 11/30/2021
Date Signed: 12/01/2021 09:39:06 AM

Document Has Been Signed on 12/01/2021 09:39 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:BROAS GUEST HOMEFACILITY NUMBER:
374601767
ADMINISTRATOR:ALBERTO BROASFACILITY TYPE:
735
ADDRESS:2231 FOWLER DRIVETELEPHONE:
(619) 470-6644
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY: 15CENSUS: 15DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Staff Benigno Guiwo and Victoria GuiwoTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required 1 - Year Visit. LPA was greeted by Staff Benigno Guiwo, identified himself, and discussed the purpose of the visit. Staff Victoria Guiwo arrived during the visit.

LPA conducted a tour with Staff Benigno Guiwo. In accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy, and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808.No deficiencies were observed during today's visit.

An exit interview was conducted with Staff Benigno Guiwo. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were emailed to Licensee Alberto Broas. A read receipt email confirms these documents were received.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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