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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603752
Report Date: 06/20/2022
Date Signed: 06/21/2022 11:07:48 AM


Document Has Been Signed on 06/21/2022 11:07 AM - 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: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:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:House Manager, Althea BordarioTIME COMPLETED:
04:24 PM
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Licensing Program Analyst Debbie Correia conducted an unannounced Required 1 -Year Visit. LPA identified herself and was greeted and allowed entry to the facility by House Manager (HM) Althea Bordario, LPA met with HM Bordario, and discussed the purpose of the visit.

During today's visit, LPA Correia, accompanied by HM Bordario, toured the facility and verified compliance with infection control practices. LPA Correia and HM Bordario, reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report. 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. Facility maintains documentation of visitor, staff, and resident vaccination records, all staff were observed with facial coverings. Infection control signs posted at facility entrance and signs were posted throughout the facility to promote universal precautions, 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 ample supply of disinfectant products and PPE.

No deficiencies were cited during today’s visit. An exit interview was conducted wit HM Bordario, and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to HM Bordario, and HM Bordario's signature below confirms receipt of the Licensing reports..
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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