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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604481
Report Date: 10/17/2022
Date Signed: 10/17/2022 12:06:12 PM

Document Has Been Signed on 10/17/2022 12:06 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:COLUMBIA RESIDENTIAL CARE LLCFACILITY NUMBER:
374604481
ADMINISTRATOR:CHANEL BERNARTEFACILITY TYPE:
735
ADDRESS:1610 COLUMBIA STREETTELEPHONE:
(858) 294-3670
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 4CENSUS: 2DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:Chanel Bernate, Licensee TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced Required 1 – Year Visit. The facility file was reviewed prior to the visit. LPA met with Chanel Bernarte, Licensee and we 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. 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.

No deficiencies were cited or observed on this date.

An exit interview was conducted. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), along with a copy of this report.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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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