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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600996
Report Date: 09/19/2022
Date Signed: 09/19/2022 01:05:11 PM

Document Has Been Signed on 09/19/2022 01:05 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:VELASCO HOMES #5, THEFACILITY NUMBER:
374600996
ADMINISTRATOR:SANFORD, LAILANI JOYFACILITY TYPE:
740
ADDRESS:1564 MALTA AVENUETELEPHONE:
(619) 476-7011
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 3DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Caregiver, Flavel CatahanTIME COMPLETED:
12:05 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, Favel Catahan and granted entry after identifying herself. LPA discussed the purpose of the visit. This facility serves six (6) residents ages 60 years and above; all of whom may be non-ambulatory.

During today's visit, LPA toured the facility, and verified compliance with infection control practices. LPA and Caregiver reviewed the facility’s COVID-19 Mitigation Plan. 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, cough and sneeze etiquette; face coverings worn by staff; 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 disinfectants.

Based on today's visit, no deficiencies were observed in the areas evaluated above. An exit interview was conducted with Caregiver Catahan and a copy of this report along with the Licensee/Appeal Rights (LIC 9058) was provided.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2022
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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