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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604497
Report Date: 04/22/2022
Date Signed: 04/22/2022 11:35:50 AM


Document Has Been Signed on 04/22/2022 11:35 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:AMPARO SENIOR CAREFACILITY NUMBER:
374604497
ADMINISTRATOR:CAPATI, ANNAFACILITY TYPE:
740
ADDRESS:1029 BOULDER PLACETELEPHONE:
(760) 576-5487
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 6DATE:
04/22/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Walter EugenioTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Post Licensing Visit. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry by Caregiver Walter Eugenio after identifying herself. LPA explained the purpose of the visit to Walter Eugenio. LPA spoke to Administrator Anna Capati on the phone during the visit.

LPA conducted a tour of the facility and observed the residents 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 or observed on this date. An exit interview was conducted with Caregiver Walter Eugenio, to whom a copy of this report and the Licensee appeal rights (LIC9058 01/16) were provided via hardcopy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
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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