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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604199
Report Date: 10/13/2022
Date Signed: 11/04/2022 12:51:19 PM


Document Has Been Signed on 11/04/2022 12:51 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/04/2022 12:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA met with Interim-Administrator, Amanda Sanner Somsen, and informed her of the purpose of the visit. There are no COVID-19 positive cases at this time.

During today's visit, the LPA toured the home and made observations pertaining to the facility's infection control measures. The LPA observed sufficient cleaning/disinfecting provisions. The facility has a Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report in place which is pending approval by the Department. The plan establishes guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. No COVID-19 training was observed on file. A citation will be issued.

Due to insufficient time, the citation will be issued at a later date. This report was reviewed with Somsen and a copy provided.

NOTE: This report was amended on November 04, 2022.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DAYBREAK VILLA SAN MARCOS
FACILITY NUMBER: 374604199
VISIT DATE: 10/13/2022
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THIS PAGE WAS INTENTIONALLY LEFT BLANK
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2