<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604193
Report Date: 08/04/2021
Date Signed: 08/05/2021 07:11:12 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:KAPAMILYA CARE HOME LLCFACILITY NUMBER:
374604193
ADMINISTRATOR:JULLIA ARIDAFACILITY TYPE:
740
ADDRESS:852 CREST DRIVETELEPHONE:
(619) 817-9475
CITY:CHULAVISTASTATE: CAZIP CODE:
91910
CAPACITY:6CENSUS: 6DATE:
08/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Administrator, Jullia AridaTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an annual required licensing inspection. This annual inspection was focused on infection control due to the COVID-19 pandemic. LPA was greeted at the front door by Administrator, Jullia Arida and granted entry after identifying herself. LPA discussed the purpose of the visit. This facility serves six (6) residents ages 60 years and above; all of whom may be non-ambulatory.

During today's visit, LPA toured the facility, and verified compliance with infection control practices. LPA and Administrator reviewed the facility’s COVID-19 Mitigation Plan Report. LPA observed one central entry point; routine symptom screening initiated at entry for staff, clients and visitors; a sign-in policy enacted for all visitors; signs throughout the facility to promote hand hygiene, cough and sneeze etiquette; 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 residents; and an adequate supply of disinfectants. LPA discussed the Provider Information Notice (PIN) regarding updated guidance on visitation.

Based on today's visit, no deficiencies were observed in the areas evaluated above. An exit interview was conducted with Administrator Arida and a copy of this report along with the Licensee/Appeal Rights (LIC 9058) was provided via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1