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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603787
Report Date: 11/18/2021
Date Signed: 12/06/2021 09:48:37 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:KINGS CARE ASSISTED LIVING LLCFACILITY NUMBER:
374603787
ADMINISTRATOR:YERKO, MARKFACILITY TYPE:
740
ADDRESS:247 PRESLEY PLACETELEPHONE:
(760) 643-1557
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY:14CENSUS: 9DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Luann Lozano, AdministratorTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself and was granted entry by Luann Lozano, Administrator. LPA met with Administrator Lozano and discussed the purpose of today’s visit.

A tour of the facility was conducted inside and out. LPA, accompanied by the Administrator conducted a general overall inspection, with specific focus on infection control protocols.

During today's inspection LPA observations include the following: Symptom screening procedures for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; testing plan and procedures was discussed; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with the Administrator. A copy of this report, along with the Licensee Rights (01/2016) was emailed to Administrator Lozano and Licensee Mark Yerko at the conclusion of the visit. LPA requested Administrator to send LPA an electronic message reply confirming receipt of these documents.

Administrator submitted a current Personnel Report LIC 500, Designation of Administrative Responsibility LIC 308 and an Emergency Disaster Plan LIC 610-E while LPA Lopez was at the facility. Form is available at www.ccld.ca.gov.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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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