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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604392
Report Date: 10/26/2021
Date Signed: 10/28/2021 04:02:14 PM

Document Has Been Signed on 10/28/2021 04:02 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:VILLALOBOS ARF #3FACILITY NUMBER:
374604392
ADMINISTRATOR:VILLALOBOS, ROGERFACILITY TYPE:
735
ADDRESS:875 MISTY MEADOW CT.TELEPHONE:
(619) 778-8469
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 4CENSUS: 3DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Licensee, Roger VillalobosTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an annual required licensing inspection. This annual inspection was focused on infection control due to the COVID-19 pandemic. Licensee arrived at the facility; however, had leave to get facility keys to gain access as the clients were away at day program. Actual visit was conducted at 10:29 am. LPA was greeted by Licensee, Roger Villalobos and granted entry after identifying herself. LPA Hamilton explained the purpose of the visit. This facility serves four (4) developmentally disabled adults ages 18 through 59 years; all of whom are ambulatory.

During today's visit, LPA toured the facility, and verified compliance with infection control practices. LPA and Licensee reviewed the facility’s COVID-19 Mitigation Plan. LPA observed one central entry point; routine symptom screening initiated at entry for staff, clients and visitors; face coverings worn by staff; hand washing stations readily available; a designated visitation area; and an adequate supply of disinfectants. LPA discussed the Provider Information Notices (PINs) regarding updated guidance on visitation and staff vaccination.

Based on today's visit, no deficiencies were observed in the areas evaluated above. An exit interview was conducted with Licensee Villalobos and a copy of this report along with the Licensee/Appeal Rights (LIC 9058) was provided via email. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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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