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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602806
Report Date: 04/08/2022
Date Signed: 04/08/2022 04:08:25 PM


Document Has Been Signed on 04/08/2022 04:08 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:HOME SWEET HOME CAREFACILITY NUMBER:
374602806
ADMINISTRATOR:NONAY, NORMA D.FACILITY TYPE:
740
ADDRESS:6811 FUJI STREETTELEPHONE:
(619) 472-9205
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY:6CENSUS: 3DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Norma Nonay, LicenseeTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Dawn Segura visited the facility to conduct an annual required licensing inspection. LPA introduced herself and was granted entry into the facility by Norma Nonay, Licensee, 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; symptom screening 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 coverings 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 and PPE.

No deficiencies were cited during today’s visit. An exit interview was conducted with Norma Nonay, and a copy of this report and Licensee Rights (LIC 9058 FAS 01/16) will be provided, via email, following the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
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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