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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604375
Report Date: 08/16/2021
Date Signed: 08/16/2021 06:24:44 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:HUNTINGTON HOUSEFACILITY NUMBER:
374604375
ADMINISTRATOR:DERAFERA, TESSFACILITY TYPE:
740
ADDRESS:14805 BUDWIN LANETELEPHONE:
(619) 625-6886
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 4DATE:
08/16/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tess Derafera, AdministratorTIME COMPLETED:
03:08 PM
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Licensing Program Analyst (LPA) Dawn Segura visited the facility to conduct a post licensing inspection. LPA was granted entry into the facility by Rosario Sales, Staff, and met with Tess Derafera, Administrator, with whom she discussed the purpose of the visit.

During today's visit, LPA toured the facility and verified compliance with infection control practices. LPA and Administrator reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation. 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 providing visitors with infection control guidance, and signs in the facility to promote hand hygiene and cough/sneeze etiquette; hand sanitizer/hand washing stations readily available; available visitation area; emergency agencies’ contact information visible to staff; and an adequate supply of cleaning products and PPE. Upon LPA's arrival, staff present was observed working without a face covering and placed one on shortly after LPA's arrival.

No deficiencies were cited during today’s visit. An exit interview was conducted with Tess Derafera, Administrator, and a copy of this report and Licensee Rights (LIC 9058 FAS 01/16) were provided to the administrator via email following the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
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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