<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602750
Report Date: 10/11/2022
Date Signed: 10/12/2022 08:45:01 AM

Document Has Been Signed on 10/12/2022 08:45 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, 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:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee Valerie JenkinsTIME COMPLETED:
02:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Iby Strong, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Licensee Valerie Jenkins and discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPA conducted a tour of the facility, both inside and outside and observed the clients in care. In accordance with the Department’s Infection Control, LPA evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.

No deficiencies were cited or observed on this date.

The Licensee was provided a copy of their appeal rights (LIC9058 03/22). An exit interview was conducted and a copy of this report was handed to Licensee Valerie Jenkins.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1