<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604328
Report Date: 09/13/2022
Date Signed: 09/13/2022 01:41:56 PM


Document Has Been Signed on 09/13/2022 01:41 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:UC CARE SENIOR LIVING IFACILITY NUMBER:
374604328
ADMINISTRATOR:KELLY, FLORAFACILITY TYPE:
740
ADDRESS:3664 GOVERNOR DRTELEPHONE:
(858) 750-3455
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY:6CENSUS: 6DATE:
09/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Licensee, Flora Kelly, and Caregiver, Armando CastroTIME COMPLETED:
01:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Sabel Martinez, visited the facility to conduct an annual required licensing inspection. The LPA was met by Armando Castro, Caregiver, and was granted entry into the facility, after disclosing the purpose of the visit. Licensee, Flora Kelly, arrived during the visit.

During today's visit, the LPA toured the facility, and verified compliance with infection control practices. The LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all 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; 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 cleaning products.

No deficiencies were cited during today’s visit. An exit interview was conducted with Licensee, Flora Kelly, to whom a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1