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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603665
Report Date: 02/11/2022
Date Signed: 02/11/2022 02:33:47 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:DEVON PLACE HOME CAREFACILITY NUMBER:
374603665
ADMINISTRATOR:MARK LOOFACILITY TYPE:
740
ADDRESS:1814 DEVON PLACETELEPHONE:
(760) 941-1818
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 6DATE:
02/11/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Mark LooTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno, and County of San Diego Senior Public Health Nurse, Sandra Brackman, conducted an in-person visit.

LPA and Nurse Brackman identified themselves and discussed the purpose of the visit with Administrator, Mark Loo.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's disinfection and screening protocols. During today's visit, the team interviewed the Administrator and provided consultation and conducted a walk-though of the facility. A debriefing was conducted with the Administrator.

During today's visit, no deficiencies were issued. An exit interview was conducted with Administrator, Loo, and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic receipt of confirmation was requested upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
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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