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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604078
Report Date: 04/12/2022
Date Signed: 04/13/2022 05:21:28 PM


Document Has Been Signed on 04/13/2022 05:21 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:MARYAM RCFEFACILITY NUMBER:
374604078
ADMINISTRATOR:DOST, LEEDAFACILITY TYPE:
740
ADDRESS:4930 MAIDEN LANETELEPHONE:
(619) 825-7398
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:6CENSUS: 6DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:House Manager Morena "Maria" LermaTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Required 1 - Year Visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with caregiver Majida "Maggie" Houaoura. House Manager Morena "Maria" Lerma arrived later during the visit.

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 Lerma. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail to Lerma and administrator Leeda Dost.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
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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