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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602860
Report Date: 08/26/2022
Date Signed: 08/26/2022 05:42:44 PM

Document Has Been Signed on 08/26/2022 05:42 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:VILLALOBOS ARFFACILITY NUMBER:
374602860
ADMINISTRATOR:ROGER VILLALOBOSFACILITY TYPE:
735
ADDRESS:6137 PARKSIDE AVENUETELEPHONE:
(619) 778-8469
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY: 4CENSUS: 4DATE:
08/26/2022
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Roger Villalobos, LicenseeTIME COMPLETED:
09:56 AM
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Licensing Program Analyst (LPA) Dawn Segura conducted an announced Case Management visit, accompanied by Nurse Elizar Perez from the Healthcare Acquired Infection (HAI) team of San Diego County Health and Human Services Agency. LPA and Nurse Perez introduced themselves, were granted entry, and met with Roger Villalobos, Licensee, and Gabriel Halog, House Manager.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation efforts to include disinfection, testing, vaccination, screening protocols, and the use of personal protective equipment (PPE). During the visit, the team conducted a visual inspection of the facility and Nurse Perez provided feedback on practices in use by the facility. A debriefing was conducted with the licensee at the conclusion of the visit.

During today's visit, no deficiencies were cited. Copies of this report and Licensee Rights (LIC 9058) were provided to the licensee at the conclusion of the visit. The signature of Roger Villalobos on this form acknowledges receipt of copies of the report and Licensee Rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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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