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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602454
Report Date: 06/29/2022
Date Signed: 06/29/2022 10:00:41 AM


Document Has Been Signed on 06/29/2022 10:00 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:LA COSTA HEIGHTS LIVING CAREFACILITY NUMBER:
374602454
ADMINISTRATOR:LINDU NAPITUPULUFACILITY TYPE:
740
ADDRESS:7626 GALLEON WAYTELEPHONE:
(760) 635-2870
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:6CENSUS: 5DATE:
06/29/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator Lindu NapitupuluTIME COMPLETED:
10:15 AM
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Licensing Program Analysts (LPA) Daniela Huerta, and County of San Diego Nurse Robert Montillano, conducted an on-site visit. LPA and Nurse identified themselves and discussed the purpose of the visit with Administrator Lindu Napitupulu.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, screening protocols as well as the use of personal protective equipment. During today's visit, Lindu Napitupulu was interviewed and a walk-though of the facility was conducted. A debriefing was conducted with the Lindu Napitupulu at the conclusion of the visit. No deficiencies were issued today.

An exit interview was conducted with the Administrator and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniela HuertaTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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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