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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604178
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:28:34 PM

Document Has Been Signed on 09/21/2022 03:28 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:CASA DE MAYAFACILITY NUMBER:
374604178
ADMINISTRATOR:GONZALEZ, JOSE A.FACILITY TYPE:
735
ADDRESS:9643 BOTE CTTELEPHONE:
(619) 201-0676
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 4DATE:
09/21/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Jose Gonzalez, AdministratorTIME COMPLETED:
10:08 AM
NARRATIVE
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Licensing Program Analyst (LPA), Tiffany Holmes, conducted an announced Case Management visit, accompanied by Nurse, Elizar Perez, from the Healthcare Acquired Infection (HAI) team of San Diego County Health and Human Services Agency. LPA Holmes and HAI nurse were allowed entry into the facility, by Administrator Jose Gonzalez after identifying themselves and stating the purpose of the visit.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan to include disinfection, testing, vaccination, and screening protocols, as well as the use of personal protective equipment (PPE). During today's visit, the caregivers/ staff were interviewed, and the team conducted a walk-though of the facility. A debriefing was conducted with the Caregivers/Staff at the conclusion of the visit.

During today's visit, no deficiencies were cited. An exit interview was conducted with Jose Gonzalez, Administrator. A copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to Administrator at the end of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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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