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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603669
Report Date: 07/07/2022
Date Signed: 07/07/2022 08:50:30 PM

Document Has Been Signed on 07/07/2022 08:50 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: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:
07/07/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Licensee David LarsonTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Correia conducted a continuation of an annual required licensing inspection. LPA was greeted at the front door by Healthcare Provider Oswaldo Jimenez. Licensee Larson granted LPA entry after identifying herself and disclosing the reason for her visit.

During today's visit, LPA Correia, accompanied by Licensee Larson, toured the facility and verified compliance with infection control practices. LPA Correia and Licensee Larson reviewed the facility’s Infection Control/Mitigation Plan specific to COVID-19. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; tracking form for visitor vaccination status and/or COVID-19 test result, 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; hand sanitizer/hand washing stations readily available; a designated visitation area when needed; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of cleaning products and PPE gear.

No deficiencies were cited during today’s visit. An exit interview was conducted with Licensee Larson and a copy of this along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to him. Signature on this form confirms receipt of the documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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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