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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604149
Report Date: 06/21/2022
Date Signed: 06/22/2022 09:32:59 AM


Document Has Been Signed on 06/22/2022 09:32 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, 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:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Carmen Campas, AdministratorTIME COMPLETED:
10:42 AM
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced annual required inspection on today's date. LPA was greeted at the front door and granted entry by Carmen Campas, Administrator, after identifying herself and disclosing the purpose of the visit. An overall tour of the facility was conducted. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other requirements most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA reviewed with Administrator the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC808). LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety. LPA observed 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; and an adequate 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 with Administrator and a copy of this report along with Licensee/Appeal Rights (LIC9058 FAS 01/16) were provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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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