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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602528
Report Date: 01/17/2022
Date Signed: 01/17/2022 04:05:40 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:ANSHIN HOME CAREFACILITY NUMBER:
374602528
ADMINISTRATOR:TODA, KUNINOBUFACILITY TYPE:
740
ADDRESS:9412 HILMER DRIVETELEPHONE:
(619) 867-2341
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:6CENSUS: 2DATE:
01/17/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Kuninobu "Kunito" TodaTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Case Management visit, accompanied by nurse contractor Sandra Brackman from the Healthcare Associated Infection (HAI) team of San Diego County Health and Human Services Agency. LPA and HAI nurse were welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Kuninobu "Kunito" Toda.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's COVID-19 screening, testing, and disinfection processes and the staff’s use of personal protective equipment. During the visit, LPA and HAI nurse delivered additional PPE supplies, briefly toured the facility, interacted with staff, and interviewed the administrator. No deficiencies were cited on this date.

An exit interview was conducted with Toda, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. LPA requested a reply E-mail or read receipt confirmation upon receipt of documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2022
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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