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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604327
Report Date: 06/21/2022
Date Signed: 06/21/2022 10:50:59 AM

Document Has Been Signed on 06/21/2022 10:50 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:ALEJANDRA'S HOME #1FACILITY NUMBER:
374604327
ADMINISTRATOR:BASURTO, ALEJANDRAFACILITY TYPE:
735
ADDRESS:1374 CARPINTERIA STREETTELEPHONE:
(619) 616-6685
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 6CENSUS: 6DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Licensee, Alejandra BasurtoTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced Required 1 - Year Visit. The LPA was greeted by Licensee, Alejandra Basurto, identified himself, and discussed the purpose of the visit.

During today's inspection, the LPA observed exterior and interior passageways were free from obstructions. All of the residents’ rooms were equipped with the required furnishings. Residents’ bathrooms were observed to be sanitary and operational. The facility was stocked with a 2-day supply of perishable and a 7-day supply of nonperishable food items.

In accordance with the Department’s Infection Control program, the LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).
The LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for visitors; Signs 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 worn by staff; Hand sanitizer/hand washing stations readily available; a designated visitation area; and emergency agencies’ contact information posted in a location visible to staff and residents. Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were cited during the visit.

An exit interview was conducted with Licensee, Alejandra Basurto, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided to.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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