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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604489
Report Date: 03/08/2022
Date Signed: 03/09/2022 08:23:40 AM


Document Has Been Signed on 03/09/2022 08:23 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:AVALON PALM CARE, INC. DBA AVALON PALMFACILITY NUMBER:
374604489
ADMINISTRATOR:WINBLAD, JASONFACILITY TYPE:
740
ADDRESS:3271 INNUIT AVETELEPHONE:
(619) 757-3918
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:6CENSUS: 6DATE:
03/08/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Malia SamuelaTIME COMPLETED:
05:50 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Post-Licensing Visit. LPA identified herself and was allowed entry by, and explained the purpose of the visit to Caregivers Ariana Saldivar and Malia Samuela. LPA spoke with Licensee Magdarline Winblad on the phone during the visit.

LPA conducted a tour of the facility and observed the clients in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, observed, and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, testing, vaccination, screening protocols, and the use of personal protective equipment.

No deficiencies were cited on this date. An exit interview was conducted with Malia Samuela. A copy of this report and the licensee appeal rights (LIC9058 01/16) were provided to the Licensee via E-mail.
SUPERVISOR'S NAME: Alexandre VoTELEPHONE: (619) 385-7506
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
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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