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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804527
Report Date: 06/25/2021
Date Signed: 06/25/2021 05:16:20 PM

Document Has Been Signed on 06/25/2021 05:16 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:LIWAG'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
370804527
ADMINISTRATOR:NORA B. LIWAGFACILITY TYPE:
740
ADDRESS:3993 CASEMAN STREETTELEPHONE:
(619) 690-1022
CITY:SAN DIEGOSTATE: CAZIP CODE:
92154
CAPACITY: 6CENSUS: 4DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 AM
MET WITH:Administrator, Nora LiwagTIME COMPLETED:
04:00 PM
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Licensing Program Analyst, Marisela Garcia-Centeno, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Nora Liwag 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 and observed the residents in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, 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.

The Licensee was provided a copy of their appeal rights (LIC9058 01/16). An exit interview was conducted with Administrator, Nora Liwag and a copy of this report was emailed to the Licensee with an electronic read receipt as confirmation of documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2021
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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