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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602991
Report Date: 09/14/2022
Date Signed: 09/14/2022 11:05:25 AM


Document Has Been Signed on 09/14/2022 11:05 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:VERDUGO BOARDING HOMEFACILITY NUMBER:
374602991
ADMINISTRATOR:JACOME, RIGOBERTO GARCIAFACILITY TYPE:
740
ADDRESS:690 HELEN DRIVETELEPHONE:
(760) 757-8403
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 6DATE:
09/14/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Rigoberto GarciaTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Rebecca Ruiz and County of San Diego Nurse Contractor Sandra Brackman with the HAI Program, conducted an on-site HAI assessment visit. LPA and team identified themselves and discussed the purpose of the visit with Administrator Rigoberto Garcia.

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 Administrator and conducted a walk-though of the facility. A debriefing was conducted at the conclusion of the visit.

No deficiencies were cited on this date. An exit interview was conducted with Rigoberto Garcia, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
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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