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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602957
Report Date: 11/18/2021
Date Signed: 11/22/2021 08:02:27 AM

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:GEORGINA BOARD & CAREFACILITY NUMBER:
374602957
ADMINISTRATOR:MOTON, SHERRYFACILITY TYPE:
740
ADDRESS:77 E GEORGINA STTELEPHONE:
(619) 422-5807
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:6CENSUS: 6DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caregiver, Katlyn CieslewiczTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an annual required licensing inspection. This annual inspection was focused on infection control due to the COVID-19 pandemic. LPA was greeted at the front door by Caregiver, Katyln Cieslewicz and granted entry after identifying herself. LPA Hamilton explained the purpose of the visit. This facility serves six (6) elderly residents; age 60 and above; four (4) of whom may be non-ambulatory.

During today's visit, LPA toured the facility and verified compliance with infection control practices. LPA and Caregiver, Cieslewicz reviewed the facility’s COVID-19 Mitigation Plan. LPA observed one central entry point; a sign-in policy enacted for all visitors, staff and residents; signs throughout the facility to promote hand hygiene, face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of PPE and disinfectants.

Based on today's visit, no deficiencies were observed in the areas evaluated above. An exit interview was conducted with Caregiver, Cieslewicz and a copy of this report along with the Licensee/Appeal Rights (LIC 9058) was provided via email. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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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