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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604343
Report Date: 10/17/2022
Date Signed: 10/17/2022 03:04:17 PM


Document Has Been Signed on 10/17/2022 03:04 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:CARABELLE SENIORS HOMEFACILITY NUMBER:
374604343
ADMINISTRATOR:DIO, JOSEPHINEFACILITY TYPE:
740
ADDRESS:920 SACRAMENTO AVE.TELEPHONE:
(619) 713-1137
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH: Administrator Josephine DioTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Kayla Hilario, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Administrator Josephine Dio and caregiver Marlina Devera. LPA identified herself and discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPA conducted a tour of the facility, both inside and outside. There are currently no residents in care. In accordance with the Department’s Infection Control, 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.

An exit interview was conducted with Administrator Josephine Dio. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator via hard copy at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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