<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604406
Report Date: 04/21/2022
Date Signed: 04/21/2022 02:20:13 PM


Document Has Been Signed on 04/21/2022 02:20 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:HENLEY PARK HOUSEFACILITY NUMBER:
374604406
ADMINISTRATOR:BUTCHER NOBLE, APRILFACILITY TYPE:
740
ADDRESS:1997 CALLE MADRIGALTELEPHONE:
(571) 299-8636
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:6CENSUS: 5DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator, April Noble and Caregiver, Ludmila GalaTIME COMPLETED:
02:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Sabel Martinez, visited the facility to conduct an annual Required- 1 year licensing inspection. The LPA was met by Ludmila Gala, Caregiver, and was granted entry into the facility, after disclosing the purpose of the visit. Administrator, April Noble, arrived during the visit.

The inspection included, but was not limited to, verifying compliance with statutes, regulations and other requirements most relevant to protecting the health of residents in care and staff, including the area of infection control practices.

During today's visit, LPA toured the facility, and verified compliance with infection control practices. The 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 with the facility’s visitor policy; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of Personal Protective Equipment (PPE).

An exit interview was conducted with Administrator, April Noble, to whom a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1