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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603713
Report Date: 07/25/2022
Date Signed: 07/25/2022 04:13:04 PM


Document Has Been Signed on 07/25/2022 04:13 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/25/2022 04:12 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

NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA was welcomed by and identified himself to Lead Receptionist Alexis Trujillo. LPA then met and discussed the purpose of the visit with Med Tech Jennifer Regala, and then Resident Service Coordinator Patricia Pestano (who arrived later during the visit).

LPA conducted a brief tour of the facility and observed the staff and residents in care. In accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, screening protocols, and the use of personal protective equipment. No deficiencies were cited on this date.

An exit interview was conducted with Pestano, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
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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