<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602728
Report Date: 08/19/2021
Date Signed: 08/19/2021 07:39:24 PM

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:RESIDENT'S PALACE, THEFACILITY NUMBER:
374602728
ADMINISTRATOR:PHYLLIS BOLTONFACILITY TYPE:
735
ADDRESS:8090 BROOKHAVEN RDTELEPHONE:
(619) 434-9231
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:4CENSUS: 4DATE:
08/19/2021
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee Phyllis Bolton and House Manager Tyrone BoltonTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst, Debbie Correia and the County of San Diego Nurses, Elizar Perez and Sandra Brackman, with the HAI Program, conducted an on-site visit. The team identified themselves and discussed the purpose of the visit with Licensee Phyllis Bolton and House Manager Tyrone Bolton.

The Department and HAI Team conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment. During today's visit, the HAI team discussed the proper use of disinfectant, how to perform hand hygiene, and 6-feet distancing. Licensee Bolton and House Manager Bolton were also provided training on how to properly don, doff, and dispose of PPE gear. A debriefing was conducted with Licensee Bolton and House Manager Bolton at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with Licensee Bolton, and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to Licensee Bolton via electronic mail. An electronic read reply confirms receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1