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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604221
Report Date: 08/06/2021
Date Signed: 08/06/2021 03:56:37 PM

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:LIFE SAVER PLACE OF VISTAFACILITY NUMBER:
374604221
ADMINISTRATOR:BALANQUIT, IEZLFACILITY TYPE:
740
ADDRESS:1185 BELMONT TERRACETELEPHONE:
(858) 284-9114
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 5DATE:
08/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Zaldy Balanquit, LicenseeTIME COMPLETED:
02:30 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 Gil Ramos, Caregiver. LPA met with Gil Ramos, Caregiver and discussed the purpose of today’s visit and Zaldy Balanquit, Licensee, later arrived at the facility.

A tour of the facility was conducted inside and out. LPA, accompanied by Gil Ramos, Caregiver 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, cough and sneeze etiquette and other infection control procedures; Hand hygiene practices; testing plan and procedures; 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 Zaldy Balanquit, Licensee. A copy of this report, along with the Licensee Rights (01/2016) was emailed to Licensee Balanquit at the conclusion of the visit. LPA requested for Licensee Balanquit to send LPA an electronic message reply confirming receipt of these documents.

LPA received a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-E via email from Licensee Balanquit during the visit. Forms are available at www.ccld.ca.gov.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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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