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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604219
Report Date: 08/30/2021
Date Signed: 08/31/2021 08:41:30 AM

Document Has Been Signed on 08/31/2021 08:41 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:REAL HOMEFACILITY NUMBER:
374604219
ADMINISTRATOR:QUITEVIS, JHODEEFACILITY TYPE:
734
ADDRESS:2281 RITTER PLACETELEPHONE:
(650) 238-4987
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY: 5CENSUS: 3DATE:
08/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Jhodee Quitevis and Lead Nurse Marvyne BanegTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Jhodee Quitevis and Lead Nurse Marvyne Baneg.

LPA conducted a brief tour of the facility and observed the clients in care. In accordance with the Department’s Infection Control, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, screening protocols, and the use of personal protective equipment. All staff encountered have a current criminal record clearance. No deficiencies were observed on this date.

An exit interview was conducted with Quitevis and Baneg, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
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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