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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602991
Report Date: 01/04/2023
Date Signed: 01/04/2023 02:59:45 PM


Document Has Been Signed on 01/04/2023 02:59 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
SO. CAL AC/SC, 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:
01/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Caregiver Jasmin MorenoTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Tammer de los Santos visited the facility to conduct an annual required licensing inspection. LPA was granted entry into the facility by Caregiver Jasmin Moreno to whom LPA 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; 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 readily available; available visitation area and an ample supply of cleaning products and personal protective equipment. LPA provided additional guidance on maintaining physical plant.

The licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agreed to submit the Infection Control Plan by March 5, 2023

No deficiencies were cited during today’s visit. An exit interview was conducted with Caregiver Jasmin Moreno, and copies of this report and Licensee Rights (LIC 9058) were provided at the conclusion of the visit. Facility representative’s signature on this form acknowledges receipt of the rights and a copy of the report.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Tammer DeLosSantosTELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
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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