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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603752
Report Date: 08/02/2021
Date Signed: 08/03/2021 05:20:58 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
FACILITY NAME:ISLAND GROVE GUEST HOME IIFACILITY NUMBER:
374603752
ADMINISTRATOR:RAMIREZ, CARMINDAFACILITY TYPE:
740
ADDRESS:12624 WILLOW ROADTELEPHONE:
(619) 454-3166
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY:12CENSUS: 9DATE:
08/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:House Manager, Kyle HernandezTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced annual
inspection on August 2, 2021. LPA Correia met House Manager Kyle Hernandez at the front door and identified herself, was granted entrance into the facility, and explained the purpose of the visit.

LPA Correia accompanied by House Manager Hernandez, conducted an overall tour of the facility inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with the House Manager, including but not limited to the following sections: Residents in Care, Staff, Visitors, Facilities without COVID-19. The facility has Plans for Infection Control, and will implement Physical Distancing as needed. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, ability to quarantine or isolate if necessary and essential health and safety.

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; 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; face coverings worn by staff and as much as possible, residents; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
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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