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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603474
Report Date: 09/28/2021
Date Signed: 09/28/2021 10:02:46 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:ISLAND GROVE GUEST HOMEFACILITY NUMBER:
374603474
ADMINISTRATOR:MARIA C WILLIAMSFACILITY TYPE:
740
ADDRESS:2150 WASHINGTON STTELEPHONE:
(619) 697-0245
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:6CENSUS: 5DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Fred Serrano, Caregiver
& Maria C Williams, Administrator		TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Fred Serrano, Caregiver and we discussed the purpose of the visit. The Administrator Maria C Williams arrived during the visit. All staff present have a current criminal record clearance.

LPA conducted a tour of the facility, both inside and outside and observed the residents in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.

No deficiencies were cited or observed on this date.

The Licensee was provided a copy of their appeal rights (LIC9058 01/16). An exit interview was conducted and a copy of this report was emailed to the Licensee with an electronic read receipt as confirmation of documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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