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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602709
Report Date: 09/03/2021
Date Signed: 10/07/2021 01:52:49 PM

Document Has Been Signed on 10/07/2021 01:52 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:CORSICA RESIDENTIAL CAREFACILITY NUMBER:
374602709
ADMINISTRATOR:BORISOVA, DANIELAFACILITY TYPE:
735
ADDRESS:514 JAMACHA ROAD 44JTELEPHONE:
(619) 456-2740
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY: 4CENSUS: 4DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Nelia TiongcoTIME COMPLETED:
11:38 AM
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Licensing Program Analyst (LPA) Kennedy made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself, and met with Nelia Tiongco, House Manager and discussed the purpose of today’s visit.

A tour of the facility was conducted inside and out. LPA, accompanied by Ms. Tiongco conducted a general overall inspection, with a specific focus on infection control.

During today's inspection LPA observations include the following: Symptom screening procedures for staff, residents and visitors; posted signs including visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; Hand hygiene practices; testing plan and procedures; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.


Based on today’s inspection, no deficiencies were observed at this time in the areas evaluated. This report was discussed with Nelia Tiongco, House Manager. A copy along with Licensee Rights (01/2016) was emailed to the licensee and administrator at the conclusion of the visit. An electronic response confirms the receipt of these documents.


Please submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-D to the licensing office within 10 business days. Forms available at www.ccld.ca.gov
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Anna Kennedy
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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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