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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602747
Report Date: 08/19/2022
Date Signed: 08/19/2022 04:10:47 PM


Document Has Been Signed on 08/19/2022 04:10 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:MARY KRYSTAL HOMEFACILITY NUMBER:
374602747
ADMINISTRATOR:LEONORA PULLINFACILITY TYPE:
740
ADDRESS:2361 MONTCLIFF ROADTELEPHONE:
(619) 267-3625
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY:6CENSUS: 5DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Leonora Pullin, AdministratorTIME COMPLETED:
02:37 PM
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Licensing Program Analyst (LPA) Dawn Segura visited the facility to conduct an annual required licensing inspection. LPA was granted entry into the facility by Leonora Pullin, Administrator, to whom she disclosed the purpose of the visit.

During today's visit, LPA toured the facility and verified compliance with infection control practices. LPA observed one central entry point for universal entry screening; temperature check initiated at entry for staff, residents, and visitors; a sign-in policy enacted for visitors; signs in the facility to promote hand hygiene, cough/sneeze etiquette, symptom and transmission awareness; face covering worn by staff; hand sanitizer/hand washing stations readily available; available visitation area; emergency agencies’ contact information visible to staff; and an ample supply of cleaning products.

No deficiencies were cited during today’s visit. An exit interview was conducted with Leonora Pullin, Administrator, and copies of this report and Licensee Rights (LIC 9058) were provided to the administrator at the conclusion of the visit. Leonora Pullin's signature on this form acknowledges receipt of the rights and a copy of the report.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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