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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604194
Report Date: 07/08/2022
Date Signed: 07/08/2022 11:49:28 AM

Document Has Been Signed on 07/08/2022 11:49 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:WIND RIVER FAMILY CAREFACILITY NUMBER:
374604194
ADMINISTRATOR:PETROV, JULIANFACILITY TYPE:
735
ADDRESS:2062 WIND RIVER ROADTELEPHONE:
(619) 447-2473
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY: 4CENSUS: 4DATE:
07/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Beatrice Acquah, CaregiverTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself and was granted entry by caregiver Beatrice Acquah. LPA met with caregiver Acquah and discussed the purpose of today’s visit. Licensee Julian Petrov and Administrator Irina Todorove arrived to join the visit.

A tour of the facility was conducted inside and out. LPA accompanied by caregiver Acquah conducted a general overall inspection, with specific focus on infection control protocols.

During today's inspection LPA observations include the following: Symptom screening procedures for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing/hand hygiene practices, cough and sneeze etiquette and other infection control procedures; testing plan and procedures for staff and clients; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Licensee Julian Petrov, Administrator Irina Todorove, and Caregiver Acquah. A copy of this report, along with the Licensee Rights (01/2016) was provided to Licensee Petrov and Administrator Todorove at the conclusion of the visit. The signature below serves as confirmation of receipt of these documents.

LPA requested for Licensee and Administrator to submit a current Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-D to the licensing office within 10 business days. LPA was provided a current Designation of Administrative Responsibility LIC 308. Forms are available at www.ccld.ca.gov.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2022
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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