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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603447
Report Date: 04/27/2021
Date Signed: 05/12/2021 01:40:01 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:ST. PANTELEIMON ELDERCAREFACILITY NUMBER:
374603447
ADMINISTRATOR:MIRIAM GAVRILKINAFACILITY TYPE:
740
ADDRESS:1537 TIBIDABO DRIVETELEPHONE:
(760) 294-2743
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 1DATE:
04/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Miriam Gavrilkina- AdministratorTIME COMPLETED:
03:04 PM
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Licensing Program Analyst (LPA) Liliana Silveira conducted a virtual case management visit via FaceTime to provide technical assistance and review the facility COVID-19 Mitigation Plan Report. LPA identified herself and discussed the purpose of the conference call with Administrator Miriam Gavrilkina.

During today's visit, LPA toured the facility and interviewed the Administrator. LPA inspected the facility’s screening areas, observed their sanitation supplies as well as PPE supplies. No deficiencies were issued during this visit.

An exit interview was conducted with Administrator Miriam Gavrilkina and a copy of this report, along with Licensee Rights (LIC 9058 01/16), was provided to her via email. An email receipt confirms the acknowledgement of these documents.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
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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