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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603306
Report Date: 06/16/2022
Date Signed: 06/16/2022 05:54:06 PM

Document Has Been Signed on 06/16/2022 05:54 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:REBECCA'S RETREATFACILITY NUMBER:
374603306
ADMINISTRATOR:REBECCA CHONGFACILITY TYPE:
775
ADDRESS:9307 TROPICO DRIVETELEPHONE:
(619) 206-0590
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 14CENSUS: 10DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Karen Graves, Caregiver and Rebecca Chong, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced Required 1 -Year Visit. LPA identified herself and was greeted and allowed entry into the facility by Karen Graves, Caregiver. LPA discussed the purpose of the visit with Rebecca Chong, Administrator via phone. Administrator arrived at the facility during the visit.

LPA conducted a tour of the facility with Karen Graves, Caregiver. In accordance with the Department’s Infection Control program, LPA provided technical assistance 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 Rebecca Chong, Administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 01/16) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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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