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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604454
Report Date: 10/05/2022
Date Signed: 10/05/2022 04:49:38 PM


Document Has Been Signed on 10/05/2022 04:49 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: 19DATE:
10/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Tess Derafera, AdministratorTIME COMPLETED:
03:11 PM
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Licensing Program Analyst (LPA) Esther Miller conducted a case management visit to give a technical violation identified during a visit. LPA entered the facility and observed two (2) staff members providing care without a mask. LPA spoke briefly with one and asked for Tess Derafera, Administrator, after identifying herself and explaining the reason for the visit. Both staff put a mask on when requested.

A technical violation was cited Per Title 22, Division 6 of the California Code of Regulations (see LIC9102). An exit interview was conducted with Administrator to whom a copy of this report and the Licensee appeal Rights (LIC9058) were provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
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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