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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603148
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:59:21 PM

Document Has Been Signed on 08/20/2021 02:59 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ANTONIO'S BOARD AND CAREFACILITY NUMBER:
374603148
ADMINISTRATOR:DULCE P. ANTONIOFACILITY TYPE:
735
ADDRESS:3737 FESTIVAL CTTELEPHONE:
(619) 271-8329
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 4DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Caregiver, Jerijan Antionio TIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an annual required licensing inspection. This annual inspection was focused on infection control due to the COVID-19 pandemic. LPA was greeted at the front door by Caregiver, Jerijan Antonio and granted entry after identifying herself. Licensee, Dulce Antonio arrived during the visit. LPA Hamilton explained the purpose of the visit with Licensee and Administrator. This facility serves four (4) adults ages 18-59; all of whom may be ambulatory.

During today's visit, LPA toured the facility, and verified compliance with infection control practices. LPA, Licensee and Caregiver reviewed the facility’s COVID-19 Mitigation Plan Report. LPA observed one central entry point; routine symptom screening initiated at entry for staff, clients and visitors; a sign-in policy enacted for all visitors; signs throughout the facility to promote hand hygiene, face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of PPE and disinfectants. LPA discussed the Provider Information Notice (PIN) regarding updated guidance on visitation.

Based on today's visit, no deficiencies were observed in the areas evaluated above. An exit interview was conducted with Licensee and Caregiver and a copy of this report along with the Licensee/Appeal Rights (LIC 9058) was provided via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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