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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604208
Report Date: 10/25/2022
Date Signed: 10/25/2022 05:38:16 PM

Document Has Been Signed on 10/25/2022 05:38 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:LIBERTY TRANQUILITYFACILITY NUMBER:
374604208
ADMINISTRATOR:SMITH, DAVIDFACILITY TYPE:
737
ADDRESS:1404 ASH STREETTELEPHONE:
(760) 654-6277
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 4CENSUS: 4DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:David Smith, Program DirectorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Dawn Segura visited the facility to conduct an annual required licensing inspection. LPA was granted entry into the facility and met with David Smith, Program Director, to whom she disclosed the purpose of the visit.

During today's visit, LPA toured the facility and verified compliance with infection control practices. LPA observed one central entry point for universal entry screening; temperature check initiated at entry for staff, residents, and visitors; a sign-in policy enacted for visitors; signs in the facility to promote hand hygiene; face coverings worn by staff; hand sanitizer/hand washing stations readily available; available visitation area; emergency agencies’ contact information visible to staff; and an ample supply of cleaning products and personal protective equipment.

No deficiencies were cited during today’s visit. An exit interview was conducted with David Smith, Program Director, and copies of this report and Licensee Rights (LIC 9058) were provided to the Program Director at the conclusion of the visit. David Smith's signature on this form acknowledges receipt of the rights and a copy of the report.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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