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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604058
Report Date: 05/27/2022
Date Signed: 05/31/2022 02:00:53 PM


Document Has Been Signed on 05/31/2022 02:00 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:NIR COMMUNITY IIFACILITY NUMBER:
374604058
ADMINISTRATOR:HUQ, RANAFACILITY TYPE:
740
ADDRESS:10935 JEFFREY COURTTELEPHONE:
(858) 414-5095
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:6CENSUS: 3DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Staff, Edith DiazTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced annual required licensing inspection. LPA was greeted and allowed entry into the facility and met with Staff, Edith Diaz. LPA stated purpose of today’s visit, to verify compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA conducted a tour of the facility and observed the residents in care. In accordance with the Department’s Infection Control, LPA provided consultation, observed, and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, testing, vaccination, screening protocols, and the use of personal protective equipment.

No deficiencies were observed during today’s visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Staff, Edith Diaz whose signature below confirms receipt of these rights.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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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