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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603896
Report Date: 11/22/2021
Date Signed: 11/22/2021 05:31:54 PM

Document Has Been Signed on 11/22/2021 05:31 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:RUSSELL HOMES MANORFACILITY NUMBER:
374603896
ADMINISTRATOR:WAINSCOTT, ANGELIAFACILITY TYPE:
735
ADDRESS:1146 SUMNER AVETELEPHONE:
(619) 749-0704
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY: 6CENSUS: 6DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Direct Support Personnel Marlik "Albert" Kelley & Licensee Shontel GrivnoTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Direct Support Personnel Marlik "Albert" Kelley. Licensee Shontel Grivno also joined in via phone.

LPA conducted a brief tour of the facility and observed the staff and residents in care. 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, to include disinfection, screening protocols, and the use of personal protective equipment. No deficiencies were cited on this date.

An exit interview was conducted with Kelley and Grivno. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail to the licensee.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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