<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603481
Report Date: 12/15/2021
Date Signed: 12/21/2021 10:36:27 AM

Document Has Been Signed on 12/21/2021 10:36 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:MARYAM ARFFACILITY NUMBER:
374603481
ADMINISTRATOR:LEEDA DOSTFACILITY TYPE:
735
ADDRESS:9319 NORTHVIEW TERRACETELEPHONE:
8583487247
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY: 6CENSUS: 6DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:House Manager, Maria LermaTIME COMPLETED:
02:42 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced annual inspection on December 15, 2021. LPA Correia met with House Manager Maria Lerma, identified herself, was granted entrance into the facility, and explained the purpose of the visit.

LPA Correia accompanied by House Manager Lerma, conducted an overall tour of the facility. 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 and updated the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with the Licensee, including but not limited to the following sections: Clients in Care, Staff, Visitors, Facilities without COVID-19. The facility has Plans for Infection Control, and will implement Physical Distancing as needed. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, ability to quarantine or isolate if necessary and essential health and safety.

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, clients and visitors; a sign-in policy enacted for all visitors; signs posted throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and as much as possible, 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 as outlined in its LIC 808.
Simon Jacob
Debbie Correia
DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MARYAM ARF
FACILITY NUMBER: 374603481
VISIT DATE: 12/15/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
No deficiencies were observed during today's visit. An exit interview was conducted with House Manager Lerma and a copy of this report along with the Licensee Rights (LIC 9058 FAS 01/16) will also be provided via email to the Licensee at the conclusion of the visit. An electronic reply response confirms receipt of these documents.
SUPERVISOR'S NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2