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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604149
Report Date: 12/31/2021
Date Signed: 12/31/2021 05:13:23 PM

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:NORTH COUNTY CARE HOMEFACILITY NUMBER:
374604149
ADMINISTRATOR:CAMPAS, CARMENFACILITY TYPE:
740
ADDRESS:15042 AMSO STTELEPHONE:
(858) 842-4608
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 5DATE:
12/31/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tom Bang, LicenseeTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Esther Miller and County of San Diego COVID-19 Site Assessment Registered Nurse Sandra Brackman with the Healthcare Associated Infection (HAI) Program conducted an on-site assessment visit. LPA and nurse identified themselves and discussed the purpose of the visit with Tom Bang, Licensee.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment (PPE). During today's visit, Licensee and care team were interviewed and conducted a walk-though of the facility. A debriefing was conducted with Licensee at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with the Licensee and a copy of this report, along with Licensee Rights (LIC9058 01/16), were provided via electronic mail. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021
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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