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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604128
Report Date: 02/28/2023
Date Signed: 02/28/2023 11:46:35 AM

Document Has Been Signed on 02/28/2023 11:46 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MOUNTAIN SHADOWS THERAPEUTIC DAY PROGRAMFACILITY NUMBER:
374604128
ADMINISTRATOR:HEARD, DONNAFACILITY TYPE:
775
ADDRESS:970 LOS VALLECITOS BLVD #130TELEPHONE:
(760) 743-3714
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 50CENSUS: 6DATE:
02/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Heath Cliff Moore, Program DirectorTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to conduct an annual inspection with an emphasis on infection control. LPA was greeted by Program Director Heath Cliff Moore, and later Community Services Program Director, Cecilia Bello. LPA identified himself, and discussed the purpose of the visit.

LPA conducted a tour with Moore and Bello, and found that 6 clients were present inside the Day Program on this date.

LPA found one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy, and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and clients, all trash receptacles were noted to have lids on them, and a 30 day supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC808. No deficiencies were observed during today's visit.

An exit interview was conducted where a copy of this report was discussed with and provided to Program Director Heath Cliff Moore.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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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