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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603328
Report Date: 09/16/2022
Date Signed: 09/16/2022 11:45:21 AM


Document Has Been Signed on 09/16/2022 11:45 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:ARBOR VICTORIAFACILITY NUMBER:
374603328
ADMINISTRATOR:RICHARD M AXTELLFACILITY TYPE:
740
ADDRESS:3410 HIGHLAND DRIVETELEPHONE:
(760) 729-4800
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:6CENSUS: 5DATE:
09/16/2022
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Administrator, Richard Axtell, and Caregiver, Ericka GarciaTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA), Sabel Martinez, and County of San Diego Nurse Contractor, Sandra Brackman, with the HAI Program, conducted an on-site HAI assessment visit. The LPA and team identified themselves and discussed the purpose of the visit with Administrator, Richard Axtell, and Caregiver, Ericka Garcia.

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, the team interviewed the Administrator and conducted a walk-though of the facility. A debriefing was conducted at the conclusion of the visit.

No deficiencies were cited on this date. An exit interview was conducted with Richard Axtell, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via electronic mail. An electronic mail read receipt confirms the documents were received by the administrator.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
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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