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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004864
Report Date: 02/15/2022
Date Signed: 02/16/2022 06:28:13 AM

Document Has Been Signed on 02/16/2022 06:28 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:ROSE GARDEN GUEST HOMEFACILITY NUMBER:
372004864
ADMINISTRATOR:JILL MCCLUREFACILITY TYPE:
740
ADDRESS:6881 MEWALL DRIVETELEPHONE:
(619) 465-7036
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 5CENSUS: 5DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Licensee, Jill McClureTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced annual
inspection on . LPA Correia met with Licensee Jill McClure the front door, identified herself, was granted entrance into the facility, and explained the purpose of the visit.

LPA and Licensee reviewed and updated the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808), including but not limited to the following sections: Residents in Care, Staff, Visitors, Facilities without COVID-19. The facility has Plans for Infection Control, and will implement Physical Distancing as needed. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, ability to quarantine or isolate if necessary and essential health and safety.

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; vaccinations and/or testing status for tracking, a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and as much as possible, residents; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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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