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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603758
Report Date: 01/28/2022
Date Signed: 01/28/2022 03:42:13 PM

Document Has Been Signed on 01/28/2022 03:42 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:
01/28/2022
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Samuel Hurtado, LicenseeTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted an announced Case Management visit, accompanied by nurses Jennifer West and Elizar Perez from the Healthcare Acquired Infection (HAI) team of San Diego County Health and Human Services Agency. LPA and nurses were granted entry and met with Samuel Hurtado, Licensee.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation efforts to include disinfection, testing, vaccination, screening protocols, and the use of personal protective equipment (PPE). During the visit, the licensee was interviewed, and the team conducted a walk-though of the facility. A debriefing was conducted with the licensee at the conclusion of the visit.

During today's visit, no deficiencies were cited. A copy of this report and Licensee Rights (LIC 9058 01/16), were provided to Samuel Hurtado, via electronic mail, following the visit. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2022
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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