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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603018
Report Date: 07/14/2021
Date Signed: 07/27/2021 09:30:17 AM

Document Has Been Signed on 07/27/2021 09:30 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:3 SISTERS HACIENDA, LLCFACILITY NUMBER:
374603018
ADMINISTRATOR:AMUNDSON, TAMARAFACILITY TYPE:
740
ADDRESS:1911 BEAR VALLEY OAKSTELEPHONE:
(760) 294-7996
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 6CENSUS: 2DATE:
07/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:House Manager, Eleanor SharpeTIME COMPLETED:
09:15 AM
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Licensing Program Analyst (LPA) Eva Torres conducted an unannounced infection control inspection. LPA met with House Manager Eleanor Sharpe. The purpose of today's visit is to inspect and ensure that the facility is following the California Code of Regulations, Title 22, Division 6. The facility is licensed for six (6) non-ambulatory elderly residents. The facility has a hospice waiver for five (5) residents.

Tour included:

Infection Control: LPA reviewed and discussed the Mitigation Plan with the house manager. LPA also provided consultation on the facility's training records, staffing plan, and screening protocols. LPA also inspected the facility's disinfectant supply and the use of personal protective equipment (PPE). Mrs. Sharpe was advised to remain updated on the changes and directions set forth by the department, so that their infection policy reflects the current information on COVID’s guidelines.

Physical Plant: front entrance, interior, and exterior surroundings were observed to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance. The facility does not have firearms and or ammunition on the grounds. There was no body of water observed on the premises.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents.

Records: All staff present have a criminal record clearance in file and are associated with the facility. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expires on 02/18/23.

Based on today’s inspection, there were no deficiencies observed per Title 22 Regulation. LPA conducted an exit interview with all staff present. A copy of this report and the Licensee Rights (LIC 9058 01/16) was emailed to administrator, and their signature on this form confirms receipt of documents.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2021
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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