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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604407
Report Date: 09/23/2021
Date Signed: 09/23/2021 02:29:34 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:BAYSHIRE CARLSBADFACILITY NUMBER:
374604407
ADMINISTRATOR:HIGHTOWER, SASHAFACILITY TYPE:
741
ADDRESS:3140 EL CAMINO REALTELEPHONE:
(760) 720-9898
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:125CENSUS: 73DATE:
09/23/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Susan PhanTIME COMPLETED:
11:41 AM
NARRATIVE
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Licensing Program Analyst (LPA) Lizzette Tellez, LPA Ramon Serrano, County of San Diego Public Health Nurses; Jennifer West, Robert Montillano, and Elizar Perez conducted an on-site HAI assessment visit. LPA Tellez, LPA Serrano and team identified themselves and discussed the purpose of the visit with Executive Director (ED) Susan Phan.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan to include disinfection, testing, vaccination, and screening protocols as well as the use of personal protective equipment (PPE). During today's visit, LPA Tellez, LPA Serrano and team conducted a walk-though of the facility. A debriefing was conducted with ED Susan Phan at the conclusion of the visit.

No deficiencies were cited during today's visit. An exit interview was conducted with ED Susan Phan and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to ED Susan Phan, via electronic mail. An electronic receipt of confirmation was requested to be sent by the ED upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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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