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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604289
Report Date: 05/28/2022
Date Signed: 05/29/2022 08:07:46 AM


Document Has Been Signed on 05/29/2022 08:07 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:CADENCE AT POWAY GARDENS - MOUNTAIN VISTASFACILITY NUMBER:
374604289
ADMINISTRATOR:BOTTOM, JASONFACILITY TYPE:
740
ADDRESS:12695 MONTE VISTA RDTELEPHONE:
(858) 312-5406
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:32CENSUS: 14DATE:
05/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator Williams and Senior Med-tech WilwagcoTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Correia conducted an unannounced annual inspection. LPA identified herself and was greeted and allowed entry to the facility by Administrator Williams and Senior Med-tech Wilwagco. LPA met with Administrator Williams and Med-Tech Wilwagco and discussed the purpose of the visit.

LPA conducted a tour of the facility, accompanied by Administrator Williams and Med-Tech Wilwagco, in accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; A sign-in policy enacted for all visitors; Face coverings worn by staff; Hand sanitizer/hand washing stations readily available; A designated visitation area; Emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit.

An exit interview was conducted with Administrator Williams to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2022
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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