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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603758
Report Date: 10/25/2021
Date Signed: 10/25/2021 07:13:12 PM

Document Has Been Signed on 10/25/2021 07:13 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:LIBEY'S ARF-AVOCADOFACILITY NUMBER:
374603758
ADMINISTRATOR:HURTADO-AYUP, MARIEFACILITY TYPE:
735
ADDRESS:4402 AVOCADO BLVDTELEPHONE:
(619) 334-9415
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 4CENSUS: 2DATE:
10/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Samuel Hurtado, LicenseeTIME COMPLETED:
12:41 PM
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Licensing Program Analyst (LPA) Dawn Segura visited the facility to conduct an annual required licensing inspection. LPA was granted entry into the facility by Jose Hurtado, Staff, to whom she disclosed the purpose of the visit. Samuel Hurtado, Licensee, arrived a short time later.

During today's visit, LPA toured the facility and verified compliance with infection control practices. LPA and Samuel Hurtado reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation. LPA observed a central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents, and visitors; a sign-in policy enacted for visitors; signs in the facility to promote hand hygiene, cough/sneeze etiquette, symptom and transmission awareness; face coverings worn by staff; hand sanitizer/hand washing stations readily available; available visitation area; emergency agencies’ contact information visible to staff; and an ample supply of cleaning products. Licensee was advised of measures that need to be implemented to increase infection control protection in the facility.

No deficiencies were cited during today’s visit. An exit interview was conducted with Samuel Hurtado, and a copy of this report and Licensee Rights (LIC 9058 FAS 01/16) will be provided to the licensee, via email, following the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2021
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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