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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603285
Report Date: 05/28/2021
Date Signed: 05/28/2021 07:18:23 PM

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:QUEEN'S MANOR HOME CAREFACILITY NUMBER:
374603285
ADMINISTRATOR:JANE TOTANESFACILITY TYPE:
740
ADDRESS:1025 BONNIE BRAE PLACETELEPHONE:
(760) 806-9455
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 5DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Roger Totanes, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez, and Licensing Program Manager, Alexandre Vo, made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA and LPM identified themselves and was granted entry by Roger Totanes, Administrator. LPA and LPM met with Roger Totanes, Administrator and discussed the purpose of today’s visit.

A tour of the facility was conducted inside and out. LPA and LPM, accompanied by Roger Totanes, Administrator conducted a general overall inspection, with specific focus on infection control protocols.

During today's inspection LPA and LPM observations include the following: Symptom screening procedures/ for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; Hand hygiene practices; testing plan and procedures; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.

Based on today’s inspection, no deficiencies were observed, but Technical Assistance was provided and reflected on the Advisory Notes. An exit interview was conducted with Roger Totanes, Administrator. A copy of this report, along with the Licensee Rights (01/2016) were emailed to Roger Totanes, Administrator at the conclusion of the visit. LPA requested for Roger Totanes, Administrator, to send LPA an electronic message reply confirming receipt of these documents.

LPA requested for Roger Totanes, Administrator, to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-E to the licensing office within 10 business days. Forms available at www.ccld.ca.gov.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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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