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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604208
Report Date: 08/19/2021
Date Signed: 08/19/2021 06:40:03 PM

Document Has Been Signed on 08/19/2021 06:40 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:BLACKSHEAR, SHAWNFACILITY TYPE:
737
ADDRESS:1404 ASH STREETTELEPHONE:
(760) 654-6277
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 4CENSUS: 2DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Morgan Davis, QA ManagerTIME COMPLETED:
03:55 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 Morgan Davis, QA Manager, with whom she discussed the purpose of the visit.

During today's visit, LPA toured the facility and verified compliance with infection control practices. LPA and Morgan Davis reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents, and visitors; a sign-in policy enacted for all visitors; signs in the facility to promote hand hygiene, cough/sneeze etiquette, symptom and transmission awareness; face coverings worn by staff; hand sanitizer/hand washing stations readily available; available visitation areas; emergency agencies’ contact information visible to staff; and a sufficient supply of cleaning products and PPE.

No deficiencies were cited during today’s visit. An exit interview was conducted with Morgan Davis, and a copy of this report and Licensee Rights (LIC 9058 FAS 01/16) were provided to Soledad Escobar, Executive Director, via email, following the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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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