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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604306
Report Date: 05/26/2021
Date Signed: 06/04/2021 01:45:16 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:DALEINA'S HOME CAREFACILITY NUMBER:
374604306
ADMINISTRATOR:CARMONA, CARINA B.FACILITY TYPE:
740
ADDRESS:815 ARCADIA PLACETELEPHONE:
(619) 475-3561
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:6CENSUS: 5DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Administrator, Carina CarmonaTIME COMPLETED:
05:05 PM
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Licensing Program Manager (LPM) John Rante and Licensing Program Analyst Marisela Garcia-Centeno conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPM and LPA met with Carina Carmona and we discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPM and LPA conducted a tour of the facility, both inside and outside and observed the clients in care. In accordance with the Department’s Infection Control, LPM and LPA provided technical assistance, evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.

No deficiencies were cited or observed on this date.

The Licensee was provided a copy of her appeal rights (LIC9058 01/16). An exit interview was conducted and a copy of this report was emailed to the Licensee with an electronic read receipt as confirmation of documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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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