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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604392
Report Date: 12/13/2021
Date Signed: 12/13/2021 03:25:12 PM

Document Has Been Signed on 12/13/2021 03:25 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:
12/13/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Roger Villalobos, LicenseeTIME COMPLETED:
02:34 PM
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Licensing Program Analyst (LPA) Esther Miller, Licensing Program Manager (LPM) Denise Powell, County of San Diego Nurse Contractors California Department Public Health (CDPH) Elizar Perez, and Health Facility Evaluator Nurse (HFEN) Sandra Brackman with the HAI Program conducted an on-site visit. LPA, LPM and team identified themselves and discussed the purpose of the visit with Roger Villalobos, Licensee.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment. During today's visit, the team interviewed Licensee and care staff and conducted a walk-though of the facility. A debriefing was conducted with Licensee at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with the Licensee and a copy of this report, along with Licensee Rights (LIC9058 01/16), were provided via electronic mail. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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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