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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603758
Report Date: 10/25/2022
Date Signed: 10/25/2022 06:08:24 PM

Document Has Been Signed on 10/25/2022 06:08 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: 3DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Licensee Samuel HurtadoTIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced required 1 -year visit. LPA identified herself was allowed entry into the facility by Licensee Samuel Hurtado, with whom LPA discussed the purpose of the visit.

LPA conducted a tour of the facility with Licensee. In accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; A sign-in policy enacted for all visitors; Face coverings worn by staff; Hand sanitizer/hand washing stations readily available; A designated visitation area; Emergency agencies’ contact information posted in a location visible to staff and clients; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in their LIC 808. No deficiencies were observed during today's visit.

An exit interview was conducted with Licensee Samuel Hurtado, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 01/16) were provided to Licensee.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2022
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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