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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602201
Report Date: 05/24/2022
Date Signed: 05/24/2022 12:31:43 PM


Document Has Been Signed on 05/24/2022 12:31 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: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:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Virgilia Rebosura Licensee/AdministratorTIME COMPLETED:
10:05 AM
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Licensing Program Manager (LPM) Denise Powell and (LPA) Amy Domingo 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 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..
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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