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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604459
Report Date: 08/10/2022
Date Signed: 08/10/2022 01:27:55 PM


Document Has Been Signed on 08/10/2022 01:27 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:GREEN VILLAFACILITY NUMBER:
374604459
ADMINISTRATOR:BRODSKY, TATIANAFACILITY TYPE:
740
ADDRESS:6396 LAKE DECATUR AVETELEPHONE:
(619) 813-9042
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY:6CENSUS: 6DATE:
08/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Caregiver Ester VillarTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Iby Strong, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Caregiver Ester Villar and discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPA conducted a tour of the facility, both inside and outside and observed the residents in care. In accordance with the Department’s Infection Control, LPA evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment. LPA also provided consultation on todays date.

No deficiencies were cited or observed on this date.

The Licensee was provided a copy of their appeal rights (LIC9058 01/16). An exit interview was conducted and a copy of this report was handed to Caregiver Ester Villar.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
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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