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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600431
Report Date: 10/21/2022
Date Signed: 10/21/2022 04:01:59 PM

Document Has Been Signed on 10/21/2022 04:01 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:EMERALD GUEST HOMEFACILITY NUMBER:
374600431
ADMINISTRATOR:PETRONILA ECHEVARRIAFACILITY TYPE:
740
ADDRESS:2558 MOBLEY STREETTELEPHONE:
(858) 430-6093
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY: 3CENSUS: 3DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Christian Atuel, CaregiverTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Riza Alvarez and Renita Hall, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPAs met with Mr. Christian Atuel, Caregiver and discussed the purpose of the visit. LPA Alvarez also talked to Administrator Petronila Echevarria for CCL's documentary requirements. All staff present have a current criminal record clearance.

LPAs 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 Alvarez 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.

Mr. Atuel was provided a copy of their appeal rights (LIC9058 03/22). An exit interview was conducted and a copy of this report was given to Mr. Atuel.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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