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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601876
Report Date: 11/19/2021
Date Signed: 11/19/2021 02:16:40 PM

Document Has Been Signed on 11/19/2021 02:16 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:MOFFAT'S ROSE HOMEFACILITY NUMBER:
374601876
ADMINISTRATOR:TRINA PACKARDFACILITY TYPE:
735
ADDRESS:9019 ILDICA STTELEPHONE:
(619) 460-2030
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 6DATE:
11/19/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Trina Packard, Administrator
& Jennifer West, COVID-19 Site
Assessment Nurse 		TIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Tiffany Holmes and County of San Diego Public Health Nurse Jennifer West conducted an on-site HAI assessment visit. LPA and team identified themselves and discussed the purpose of the visit with Program Administrator Trina Packard.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan to include disinfection, testing, vaccination, and screening protocols as well as the use of personal protective equipment (PPE). During today's visit, LPA and team conducted a walk-though of the facility, and a debriefing was conducted with Packard at the conclusion of the visit.

No deficiencies were cited during today's visit.

An exit interview was conducted with Packard, and a copy of this report, along with Licensee Rights (LIC 9058 01/16), will be provided via electronic mail. An electronic read receipt will serve as confirmation of receipt of documents.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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