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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603381
Report Date: 09/10/2021
Date Signed: 09/13/2021 09:30:36 AM

Document Has Been Signed on 09/13/2021 09:30 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:HUMMINGBIRD HILLFACILITY NUMBER:
374603381
ADMINISTRATOR:CHRIS B. CONKLINFACILITY TYPE:
740
ADDRESS:1027 CALLE DE LIMARTELEPHONE:
(760) 723-9414
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 5CENSUS: 0DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:56 PM
MET WITH:Administrator, Chris ConklinTIME COMPLETED:
05:48 PM
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Licensing Program Analyst (LPA), Kristina Ryan conducted an unannounced annual required licensing inspection. LPA was granted entry and met with Administrator, Chris Conklin. LPA was granted entry after identifying herself and disclosing the purpose of the visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Ms. Conklin, including the following sections: Person in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility has plans for infection control and physical distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention, and essential health and safety.

Facility currently has no residents in care and is not planning on accepting any new residents at this time. LPA observed one central entry point for universal entry screening, hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of PPE. The facility in in compliance with and has implemented infection control practices as outlined in its LIC 808.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Ms. Conklin. A copy of this report, along with the Licensee Rights (9058 01/16) was emailed to the administrator at the conclusion of the visit, an electronic response confirms the receipt of these documents.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Kristina Ryan
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2021
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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