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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604384
Report Date: 03/25/2022
Date Signed: 03/25/2022 07:53:34 PM

Document Has Been Signed on 03/25/2022 07:53 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:JOSEPHINE'S HOME 2FACILITY NUMBER:
374604384
ADMINISTRATOR:SO, JOSEFINA M.FACILITY TYPE:
735
ADDRESS:1452 MULLIGAN HILL STTELEPHONE:
(619) 948-7101
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 4CENSUS: 4DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Josefina SoTIME COMPLETED:
05:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Licensee Josefina So.

LPA conducted a tour of the facility and observed the clients in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, observed, and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, testing, vaccination, screening protocols, and the use of personal protective equipment. LPA reviewed and approved the facility's COVID-19 Mitigation Plan.

No deficiencies were cited or observed on this date. An exit interview was conducted with Licensee, to whom a copy of this report and the licensee appeal rights (LIC9058 01/16) were provided via E-mail.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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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