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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604273
Report Date: 03/17/2022
Date Signed: 03/17/2022 04:58:29 PM


Document Has Been Signed on 03/17/2022 04:58 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:CASA MAHALFACILITY NUMBER:
374604273
ADMINISTRATOR:FRAZIER, THERESAFACILITY TYPE:
740
ADDRESS:12631 CASA AVENIDATELEPHONE:
(858) 924-1136
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 5DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Myrna Arcelao, LicenseeTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced annual required inspection on today's date. LPA was greeted at the front door and granted entry by Teresita "Tess" Duclayan, caregiver, after identifying herself and disclosing the purpose of the visit. An overall tour of the facility was conducted. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other requirements most relevant to protecting the health of residents in care and staff, including in the area of infection control practices. Myrna Arcelao, Licensee, arrived after the tour.

LPA reviewed with Administrator, the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC808) including the following sections: Persons in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility Plans for Infection Control, and Physical Distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety. LPA observed one central entry point for universal entry screening. Although there was a visitor sign in sheet with routine symptom screening questions, there was a lack of a working thermometer. Signs were posted at facility entrance with the facility’s visitor policy, and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing. Face coverings were not worn by staff, visitors, or Licensee upon LPA's arrival. Hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of PPE (Personal Protective Equipment).

Based on observations, the facility was issued technical assistance for face coverings and visitation policy. An exit interview was conducted with Administrator, and a copy of this report along with Licensee/Appeal Rights (LIC9058 FAS 01/16) was provided via email; facility representative expressed that they would send LPA a confirmation email upon receipt of these documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
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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