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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602712
Report Date: 07/28/2022
Date Signed: 07/28/2022 11:54:54 AM


Document Has Been Signed on 07/28/2022 11:54 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:ANNE'S PLACE IVFACILITY NUMBER:
374602712
ADMINISTRATOR:ANA OSBORNEFACILITY TYPE:
740
ADDRESS:2870 WANEK ROADTELEPHONE:
(760) 233-5878
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:10CENSUS: 8DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Dearme Doverte, House ManagerTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct an annual inspection. LPA was granted entry by Caregiver Corazon. LPA was screened for COVID symptoms and elevated temperature upon entry. House Manager Dearme Doverte was notified of LPA's presence in the facility and arrived shortly thereafter as well as Licensee Ana Osbourne The facility has submitted an Infection Control Plan as required.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, proper use of face coverings, and adequate COVID postings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has an approved plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. 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 and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.
Based on the observations made during today’s visit, there were no deficiencies observed. An exit interview to review this report was conducted with Doverte and a copy of this report was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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