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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603299
Report Date: 02/08/2022
Date Signed: 02/14/2022 06:57:02 PM

Document Has Been Signed on 02/14/2022 06:57 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:DIEGO'S ADULT RESIDENTIAL CARE FACILITYFACILITY NUMBER:
374603299
ADMINISTRATOR:SHANA HAUGUMFACILITY TYPE:
735
ADDRESS:9787 HAWLEY ROADTELEPHONE:
(619) 561-2304
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY: 6CENSUS: 6DATE:
02/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator Shana HaugumTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Liliana Silveira, and County of San Diego Public Health Nurses, Elizar Perez and Jennifer West, with the Healthcare-Associated Infections (HAI) Program, conducted an on-site HAI assessment visit. LPA and team identified themselves and discussed the purpose of the visit with Administrator Shana Haugum.

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, LPA and team conducted a walk-though of the facility. A debriefing was conducted with Shana Haugum at the conclusion of the visit.

No deficiencies were cited during today's visit. An exit interview was conducted with Shana Haugum, and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator via email. An electronic receipt of confirmation confirms that the report was received.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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