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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603669
Report Date: 10/29/2021
Date Signed: 11/01/2021 05:05:25 AM

Document Has Been Signed on 11/01/2021 05:05 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:HABILITATIVE HOMES RESIDENTIAL CARE FACILITYFACILITY NUMBER:
374603669
ADMINISTRATOR:DAVID LARSONFACILITY TYPE:
735
ADDRESS:11775 WALNUT ROADTELEPHONE:
(619) 270-4484
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 6CENSUS: 6DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Administrator David LarsonTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Debbie Correia attempted to conduct an unannounced visit for an annual inspection. Upon arrival LPA called Administrator David Larson, identified herself, and inquired about the COVID status of the facility to ensure the use of proper PPE. Administrator Larson informed LPA, all clients and staff, including himself, were on a day outing to Pine Valley.

LPA Correia briefly discussed the new the guidelines regarding staff, client, and visitation vaccination and/or testing requirements. The facility's Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) has been reviewed and approved. Administrator Larson will update the Mitigation Plan with the most current requirements for submission and approval. This annual inspection requires an additional continuation.

LPA Correia conducted an exit interview via telephone with Administrator Larson. Administrator Larson was provided email with an electronic copy of the Licensing Report (LIC809), and an email read response receipt confirms receipt of the report.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2021
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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