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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603523
Report Date: 09/29/2022
Date Signed: 09/30/2022 07:26:35 AM


Document Has Been Signed on 09/30/2022 07:26 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:SHADED ARBOR GROVELAND TERRACEFACILITY NUMBER:
374603523
ADMINISTRATOR:CHERRY ANN LLANESFACILITY TYPE:
740
ADDRESS:1412 GROVELAND TERRACETELEPHONE:
(619) 631-7000
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY:6CENSUS: 6DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator Cherry Ann LlanesTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced annual required licensing inspection. LPA was granted entry by Caregiver Maricris DelaCruz after identifying herself and disclosing the purpose of the visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with COVID-19 infection control practices.

The tour was conducted with Administrator Cherry Ann Llanes. LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Infection Control, including the following sections: Persons in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility's 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 reviewed items pertaining to central entry points for universal entry screening; routine symptom screening initiated for staff, residents and 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; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and clients; and an adequate supply of PPE.

No deficiencies were cited during this visit. An exit interview was conducted with Cherry Ann. A copy of this report, along with the Licensee Rights (9058 01/16) were provided to Cherry at the facility.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
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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