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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602750
Report Date: 01/21/2022
Date Signed: 01/21/2022 04:17:30 PM

Document Has Been Signed on 01/21/2022 04:17 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:ELMIRA HOME CAREFACILITY NUMBER:
374602750
ADMINISTRATOR:JENKINS, VALERIEFACILITY TYPE:
735
ADDRESS:361 ELMIRA STREETTELEPHONE:
(619) 749-9761
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY: 4CENSUS: 4DATE:
01/21/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Mel JenkinsTIME COMPLETED:
03:38 PM
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 Licensing Program Analyst (LPA) Kennedy and County of San Diego Nurse Contractors, Jen West with the HAI Program, conducted an on-site HAI assessment visit. LPA and team identified themselves and discussed the purpose of the visit with Javetta Taylor, Caregiver. Licensee Mel Jenkins joined the LPA and the nurse at the facility.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan to include disinfection, testing, vaccination, and screening protocols as well as the use of personal protective equipment (PPE). During today's visit, the team interviewed the Caregiver Javetta Taylor and Licensee and Mel Jenkins and conducted a walk-though of the facility. A debriefing was conducted at the conclusion of the visit.

During today's visit, no deficiencies were cited.  An exit interview was conducted with the Mel Jenkins, Licensee. A copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the administrator via electronic mail.  An electronic receipt of confirmation was requested upon receipt of the documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Anna Kennedy
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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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