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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603478
Report Date: 05/28/2021
Date Signed: 05/28/2021 03:09:02 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:CHAMPINE MANORFACILITY NUMBER:
374603478
ADMINISTRATOR:SRBIJANKA ZIVKUFACILITY TYPE:
740
ADDRESS:1725 TOBACCO ROADTELEPHONE:
(760) 747-3878
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 5DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Srbijanka Zivku, LicenseeTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Adam Hamer conducted an unannounced annual required licensing inspection on today's date. LPA was greeted at the front door by Michelle Valadez, and was granted entry after identifying himself and disclosing the purpose of the visit. Licensee Srbijanka Zivku was also present and LPA conducted an overall tour of the facility was with Ms. Zivku, 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 Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Ms. Zivku, 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.

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and residents; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices.

No deficiencies were observed during today's visit. An exit interview was conducted with Ms. Zivku and a copy of this report along with the Licensee Rights (LIC 9058 FAS 01/16) was provided to her via email; an email read receipt confirms receipt of these rights.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam HamerTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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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