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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602731
Report Date: 07/30/2021
Date Signed: 10/07/2021 01:53:44 PM

Document Has Been Signed on 10/07/2021 01:53 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:YAWIPI ARFFACILITY NUMBER:
374602731
ADMINISTRATOR:BRAVO, MARTHA CAROFACILITY TYPE:
735
ADDRESS:3827 WILD OATS LANETELEPHONE:
(619) 399-5875
CITY:BONITASTATE: CAZIP CODE:
91902
CAPACITY: 4CENSUS: 4DATE:
07/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Martha CaroTIME COMPLETED:
01:06 PM
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Licensing Program Analyst (LPA) Kennedy made a visit to the facility to conduct an annual required licensing inspection. LPA identified herself, and met with Martha Caro, and discussed the purpose of today’s visit.

A tour of the facility was conducted inside and out. LPA, accompanied by Ms. Caro conducted a general overall inspection, with 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 Ms. Martha Caro. A copy along with Licensee Rights (01/2016) was emailed to Ms. Caro 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: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2021
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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