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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603862
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:13:04 PM

Document Has Been Signed on 05/12/2022 12:13 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:VILLA SANTA ROSAFACILITY NUMBER:
374603862
ADMINISTRATOR:ENRIQUEZ,RICHARDFACILITY TYPE:
735
ADDRESS:4516 PASEO DE LA VISTATELEPHONE:
(619) 948-9177
CITY:BONITASTATE: CAZIP CODE:
91902
CAPACITY: 4CENSUS: 4DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Manager, Elizabeth EnriquezTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA), Marisela Garcia-Centeno, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Manager, Elizabeth Enriquez and we discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPA conducted a tour with Caregiver, Wilberto Torres. 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; signs posted at facility entrance with the facility’s visitor policy, and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; 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 residents; 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 its Mitigation Plan (LIC 808).

An exit interview was conducted with Manager, Enriquez. The Manager was provided a copy of this report and their appeal rights (LIC9058 01/16) at the conclusion of the exit conference.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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