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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603832
Report Date: 10/21/2022
Date Signed: 10/21/2022 12:27:23 PM

Document Has Been Signed on 10/21/2022 12:27 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CHLOE'S BOARD & CAREFACILITY NUMBER:
374603832
ADMINISTRATOR:GUMABON, SR, REMEDORFACILITY TYPE:
735
ADDRESS:1608 BULL CANYON RDTELEPHONE:
(858) 610-1856
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 4CENSUS: 4DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Remedor Gumabon Jr.TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Nacole Patterson visited the facility to conduct an annual required licensing inspection. LPA was granted entry into the facility by Administrator Remedor Gumabon Jr., to whom the purpose of the visit was disclosed.

During today's visit, LPA toured the facility and was accompanied by Remedor Gumabon Jr. LPA verified compliance with infection control practices. LPA observed one central entry point for universal entry screening; temperature check 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 covering 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.

No deficiencies were cited during today’s visit. An exit interview was conducted with Remedor Gumabon Jr. and copies of this report and Licensee Rights (LIC 9058) were provided at the conclusion of the visit. His signature on this form acknowledges receipt of the rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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