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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604057
Report Date: 01/04/2022
Date Signed: 02/11/2022 06:44:20 AM

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:PLATEAU VILLAGE MEMORY CAREFACILITY NUMBER:
374604057
ADMINISTRATOR:DIVINA NUNEZFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:56CENSUS: 35DATE:
01/04/2022
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Executive Director Divinia NunezTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an announced Case Management visit, accompanied by nurse contractor Jennifer West from the Healthcare Acquired Infection (HAI) team of San Diego County Health and Human Services Agency. LPA and HAI met with Executive Director (ED) Nunez identified themselves and discussed the purpose of the visit.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's COVID-19 screening, testing, and disinfection processes, and the staff’s use of personal protective equipment (PPE), in conjunction with the facility's LIC808 COVID-19 Mitigation Plan. LPA, HAI, and the ED also conducted a tour of the facility, and observed and briefly spoke with residents in care. No deficiencies were cited during the visit.

An exit interview was conducted with ED Nunez, to whom a copy of this report (LIC 809), will be provided electronically were provided to ED Nunez via E-mail. An electronic email read response confirms receipt of the reports.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
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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