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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604454
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:22:59 PM


Document Has Been Signed on 03/10/2022 03:22 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:HUNTINGTON MANORFACILITY NUMBER:
374604454
ADMINISTRATOR:DERAFERA, TESSFACILITY TYPE:
740
ADDRESS:14755 BUDWIN LNTELEPHONE:
(619) 625-6886
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:21CENSUS: 20DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Manuel "Nick" Delacruz, CaregiverTIME COMPLETED:
01:27 PM
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced annual required inspection on today's date. LPA was greeted at the front door and granted entry by Owen Gonzalez, caregiver, after identifying herself and disclosing the purpose of the visit. An overall tour of the facility was conducted. 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 in the area of infection control practices.

LPA reviewed with Manuel "Nick" Delacruz, Caregiver, the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC808) including the following sections: Persons in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility Plans for Infection Control, and Physical Distancing. LPA observed one central entry point for universal entry screening, routine symptom screening initiated at entry for staff and visitors, and a sign-in policy enacted for all visitors but was not being enforced by staff. Signs posted at facility entrance with the facility’s visitor policy, and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by most 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 PPE (Personal Protective Equipment).

An exit interview was conducted with Delacruz, and a copy of this report, along with Technical Assistance (LIC 9102) and Licensee/Appeal Rights (LIC9058) were provided via email; facility representative expressed that they would send LPA a confirmation email upon receipt of these documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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