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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604476
Report Date: 01/21/2022
Date Signed: 01/24/2022 11:18:05 AM

Document Has Been Signed on 01/24/2022 11:18 AM - 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:NEW VISION HOMES ARFFACILITY NUMBER:
374604476
ADMINISTRATOR:BELTRAN, YESENIAFACILITY TYPE:
735
ADDRESS:859 LACEBARK ST.TELEPHONE:
(760) 270-1174
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 4CENSUS: 0DATE:
01/21/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator Yesenia BeltranTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Sabel Martinez, conducted a scheduled Pre-licensing inspection to observe the physical plant for compliance and conduct Comp III. The fire department completed their inspection on 8/23/21. Facility is approved for Four (4) residents.

LPA was greeted by Administrator Yesenia Beltran. LPA was granted entry after identifying himself and disclosing the purpose of the visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

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 and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; 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 PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. LPA discussed with the applicant continuing operation requirements, record keeping, reporting requirement and physical plant compliance.

The Pre-licensing and Component III were completed on today's date. Facility is ready for Licensure pending management approval. An exit interview was conducted with Administrator Yesenia Beltran. A copy of this report along with Applicant/Appeal Rights (LIC9058 01/16) were emailed to Administrator Beltran. An electronic email read receipt confirms the documents were received.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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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