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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603148
Report Date: 09/26/2022
Date Signed: 09/26/2022 03:20:34 PM

Document Has Been Signed on 09/26/2022 03:20 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:ANTONIO'S BOARD AND CAREFACILITY NUMBER:
374603148
ADMINISTRATOR:DULCE P. ANTONIOFACILITY TYPE:
735
ADDRESS:3737 FESTIVAL CTTELEPHONE:
(619) 271-8329
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 4DATE:
09/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Dulce AntonioTIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Correia conducted an unannounced annual inspection. LPA Correia identified herself, and was allowed entry to the facility by Administrator Dulce Antonio.

LPA conducted a tour of the facility, accompanied by Administrator Antonio, to ensure compliance with the Department’s Infection Control Policy. LPA provided technical assistant and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; A sign-in policy enacted for all visitors; Face coverings worn by staff; Hand sanitizer/hand washing stations readily available; A designated visitation area; Emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit.

An exit interview was conducted with Administrator Dulce Antonio to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) will be provided. Signature on this form confirms receipt of the reports.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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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