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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603656
Report Date: 06/27/2022
Date Signed: 06/27/2022 01:42:52 PM


Document Has Been Signed on 06/27/2022 01:42 PM - 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:CMG BOARD AND CAREFACILITY NUMBER:
374603656
ADMINISTRATOR:BIENVENIDO ROSARIOFACILITY TYPE:
740
ADDRESS:7815 MT. VERNON STREETTELEPHONE:
(619) 565-3331
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:6CENSUS: 6DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:House Manager Maricon GeronimoTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Kayla Hilario, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA identified herself and disclosed the purpose of the visit. LPA was allowed entry by Caregivers Rosario Africa and Bienvenido Rosario. All staff present have a current criminal record clearance. New Administrator/House Manager Maricon Geronimo arrived during the visit.

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.

An exit interview was conducted with Maricon Geronimo. A copy of this report and appeal rights (LIC9056 01/16), were provided via hardcopy at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
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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