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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603447
Report Date: 10/19/2020
Date Signed: 10/19/2020 11:42:01 AM

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:ST. PANTELEIMON ELDERCAREFACILITY NUMBER:
374603447
ADMINISTRATOR:MIRIAM GAVRILKINAFACILITY TYPE:
740
ADDRESS:1537 TIBIDABO DRIVETELEPHONE:
(760) 294-2743
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 3DATE:
10/19/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee Miriam GavrilkinaTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Raymond Wu conducted an unannounced Case Management visit, via FaceTime due to COVID-19, on this date in response to a request for a Hospice Waiver. LPA met with Licensee Miriam Gavrilkina and discussed the purpose of the visit.

During today's visit, a virtual walkthrough and individuals were interviewed.

No deficiencies or immediate health or safety concerns were noted during the visit.

An exit interview was conducted and a copy of this report, along with Licensee's Rights (LIC 9058 01/16), was provided to the Licensee via electronic mail. An electronic read receipt was requested to be sent by the Licensee.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Raymond WuTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020
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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