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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603693
Report Date: 06/16/2022
Date Signed: 06/16/2022 12:55:01 PM

Document Has Been Signed on 06/16/2022 12:55 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:KALEA HOUSEFACILITY NUMBER:
374603693
ADMINISTRATOR:LAURA GARCIAFACILITY TYPE:
735
ADDRESS:1312 SAN MIGUEL AVENUETELEPHONE:
(619) 303-9108
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 4DATE:
06/16/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Laura Garcia, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Tiffany Holmes, conducted an announced Case Management visit, accompanied by Nurse, Sandra Brackman, from the Healthcare Acquired Infection (HAI) team of San Diego County Health and Human Services Agency. LPA Holmes and HAI nurse were allowed entry into the facility, by caregiver Cynthia Gilsdorf, after identifying themselves and stating the purpose of the visit. Laura Garcia the Administrator arrived during the visit.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan to include disinfection, testing, vaccination, and screening protocols, as well as the use of personal protective equipment (PPE). During today's visit, the caregivers, and staff were interviewed, and the team conducted a walk-though of the facility. A debriefing was conducted with the Caregivers and Staff at the conclusion of the visit.

During today's visit, no deficiencies were cited. An exit interview was conducted with Laura Garcia, Administrator. A copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to Administrator.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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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