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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603345
Report Date: 12/24/2021
Date Signed: 12/27/2021 04:15:10 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:JOSTER VILLAFACILITY NUMBER:
374603345
ADMINISTRATOR:HERMINIA SANTOSFACILITY TYPE:
740
ADDRESS:10864 WORTHING AVENUETELEPHONE:
(858) 860-5135
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:6CENSUS: 4DATE:
12/24/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Licensee, Herminia Santos.TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA), Natasha Persaud and County of San Diego Nurse Contractor Robert Montillano conducted an on-site visit. LPA and Nurses identified themselves and discussed the purpose of the visit with Licensee, Herminia Santos.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, screening protocols as well as the use of personal protective equipment. During today's visit, Licensee was interviewed and a walk-though of the facility was conducted. A debriefing was conducted with the Licensee at the conclusion of the visit. No deficiencies were issued today.

An exit interview was conducted with the Licensee and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Licensee via electronic mail. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2021
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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