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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602607
Report Date: 08/24/2022
Date Signed: 08/24/2022 01:42:33 PM

Document Has Been Signed on 08/24/2022 01:42 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:DIVINE GRACE BOARD AND CARE IIIFACILITY NUMBER:
374602607
ADMINISTRATOR:CASTILLO, SEVEROFACILITY TYPE:
735
ADDRESS:9315 FRANCIS DRIVETELEPHONE:
(619) 303-2520
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 5DATE:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Antonio "Tony" QuiranteTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Renita Hall with Licensing Program Manager Denise Powell (LPM) conducted an unannounced Required 1 – Year Visit. The facility file was reviewed prior to the visit. LPA and LPM met with Antonio Quirante and we discussed the purpose of the visit. All staff present have a current criminal record clearance. House Manager Jose Ariel Mangulabnan arrived during visit.


LPA and LPM conducted a tour of the facility, both inside and outside. In accordance with the Department’s Infection Control, LPA and LPM 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 or observed on this date. Additional guidance was provided use of mask and storage of supplies.

An exit interview was conducted. The House Manager was provided a copy of their appeal rights (LIC9058 01/16), along with a copy of this report.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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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