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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603863
Report Date: 04/12/2022
Date Signed: 04/12/2022 04:58:24 PM

Document Has Been Signed on 04/12/2022 04:58 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 SAN JAVIERFACILITY NUMBER:
374603863
ADMINISTRATOR:ENRIQUEZ,RICHARDFACILITY TYPE:
735
ADDRESS:725 CAMELOT PARKWAYTELEPHONE:
(619) 948-9177
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY: 4CENSUS: 4DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Elizabeth Enriquez, AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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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 Claudia Moreno, Direct Support Professional (DSP). LPA met with DSP Moreno and Rosalina Rubio de Vidrio, DSP, and discussed the purpose of today’s visit. Administrator Elizabeth Enriquez later arrived and joined the inspection.

A tour of the facility was conducted inside and out. LPA accompanied by DSPs Moreno and Rubio de Vidrio 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. Hand hygiene practices; testing plan and procedures; plans for containing infections, PPE supplies, procedures and training; and disinfection procedures was discussed with Administrator Enriquez.

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

LPA requested Administrator Enriquez to submit a current Designation of Administrative Responsibility LIC 308 and a Personnel Report LIC 500 to the licensing office within 10 business days. Forms available at www.ccld.ca.gov. An Emergency Disaster Plan LIC 610-D was updated and submitted to the LPA during the visit.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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