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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604057
Report Date: 02/18/2022
Date Signed: 02/19/2022 10:20:53 PM


Document Has Been Signed on 02/19/2022 10:20 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: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: 34DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Executive Director Divinia NunezTIME COMPLETED:
04:23 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced annual required licensing inspection, focused on the facilities protocols and procedures in place regarding COVID-19 infection control. LPA Correia identified herself to Executive Director (ED) Divinia Nunez, was granted entrance into the facility, and explained the purpose of the visit.

During today's visit, LPA Correia, accompanied by the ED Nunez, toured the facility and verified compliance with infection control practices. LPA Correia reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report. LPA Correia observed the facility's one central entry point for universal screening; including routine symptom screening, vaccination tracking and/or COVID-19 test results, and a sign-in policy enacted for all visitors; signs posted at the entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; hand sanitizer/hand washing stations readily available; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of cleaning products and PPE gear.

No deficiencies were cited during today’s visit. An exit interview was conducted with ED Nunez and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to ED Nunez via email. A reply email or return receipt from the ED will confirm receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
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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