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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602201
Report Date: 05/28/2021
Date Signed: 05/28/2021 03:38:01 PM

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:CASA DEL CIELOFACILITY NUMBER:
374602201
ADMINISTRATOR:VIRGILIA REBOSURAFACILITY TYPE:
740
ADDRESS:6173 ADELAIDE AVETELEPHONE:
(619) 286-2794
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:6CENSUS: 6DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Virgilia "Gigie" RebosuraTIME COMPLETED:
02:50 PM
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Licensing Program Manager (LPA) Dang Nguyen and (LPM) Rebecca Hedgecock conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPM and LPA met with and were allowed entry by Licensee Virgilia "Gigie" Rebosura and we discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPA and LPM conducted a brief tour of the facility and observed the residents in care. In accordance with the Department’s Infection Control, LPM and LPA provided technical assistance, and 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 on this date.

An exit interview was conducted with the licensee, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. A reply E-mail or read receipt confirmation was requested from the licensee upon receipt of documents.

SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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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