<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603739
Report Date: 11/18/2022
Date Signed: 11/18/2022 06:33:24 PM


Document Has Been Signed on 11/18/2022 06:33 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:VICTORIA ESTATES SUITESFACILITY NUMBER:
374603739
ADMINISTRATOR:RETZER, MICHELLEFACILITY TYPE:
740
ADDRESS:14550 VICTORIA ESTATES LANETELEPHONE:
(858) 668-2886
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 6DATE:
11/18/2022
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Michelle Retzer, Administrator.TIME COMPLETED:
02:02 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Esther Miller and County of San Diego COVID-19 Site Assessment Registered Nurse Jennifer West with the Healthcare Associated Infection (HAI) Program conducted an on-site visit. LPA and nurse identified themselves and discussed the purpose of the visit with Michelle Retzer, Administrator.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment. During today's visit, Administrator was interviewed and conducted a walk-though of the facility. A debriefing
was conducted with Administrator at the conclusion of the visit.

LPA provided guidance on fit testing and COVID reporting requirements.

During today's visit, no deficiencies were issued. An exit interview was conducted with the Administrator and
a copy of this report, along with Licensee Rights (LIC9058), were provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1