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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602589
Report Date: 10/24/2022
Date Signed: 10/24/2022 11:14:34 AM


Document Has Been Signed on 10/24/2022 11:14 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MARY KATHERINE'S COTTAGEFACILITY NUMBER:
374602589
ADMINISTRATOR:ROSALINA BAUNFACILITY TYPE:
740
ADDRESS:1889 ALMAGRO LANETELEPHONE:
(760) 415-6348
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 5DATE:
10/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Joanna Dizon, CaregiverTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct an annual inspection with emphasis on infection control. LPA met with Caregiver Joanna Dizon and explained the purpose of today’s visit. The facility has a Mitigation Plan Report (Plan) on file as required however, an Infection Control Plan has not been received. The Licensee was granted a waiver under the authority of Governor Newsome's Executive Order N-11-22 issued on June 17, 2022, and the Licensee agreed to submit the Infection Control Plan by December 24, 2022.

During the inspection, LPA inspected the facility for regulatory compliance related to infection control. LPA observed appropriate COVID-19 screening upon entrance to the facility. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). As documented in the Plan, the facility has a designated infection control lead person/infection preventionist who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring staff are trained in the facility's infection control procedures, and ensuring infection control measures are implemented. Also as per the Plan, the facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for residents and staff with COVID-19 positive results and/or exposures. Lastly, the Plan indicates the facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician, emergency personnel, and responsible party in the event the resident presents with any COVID-19 symptoms.

No deficiencies were observed during today's visit. An exit interview was conducted, and a copy of this report was provided along with LIC9102- Advisory Notes Technical Assistance.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
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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