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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601035
Report Date: 11/08/2021
Date Signed: 11/09/2021 07:51:57 AM

Document Has Been Signed on 11/09/2021 07:51 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:LUCY'S PLACEFACILITY NUMBER:
374601035
ADMINISTRATOR:LUCIA B.TOTANESFACILITY TYPE:
740
ADDRESS:4770 ELM TREE DRIVETELEPHONE:
(760) 806-3873
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY: 6CENSUS: 4DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Administrator, Lucia TotanesTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Kristina Ryan conducted an unannounced annual required licensing inspection. LPA was granted entry by Caregiver, Victoria Dao and met with Administrator, Lucia Totanes. LPA was granted entry after identifying herself and disclosing the purpose of the visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Lucia Totanes including the following sections: Person in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility has plans for infection control and physical distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention, and essential health and safety.

LPA observed one central entry point for universal entry screening; routine symptom screening will be initiated at entry for staff, residents and visitors; a sign-in policy will be enacted for all visitors; signs will be 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 encouraged for residents; hand sanitizer/hand washing stations readily available; a designated outdoor visitation area; emergency agencies’ contact information will be posted in a location visible to staff and residents. Additional resources for PPE were discussed. The facility needed assistance to be in compliance with and implement infection control practices as outlined in its LIC 808.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Kristina Ryan
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: LUCY'S PLACE
FACILITY NUMBER: 374601035
VISIT DATE: 11/08/2021
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Based on today’s inspection, no deficiencies were cited. An exit interview was conducted with Lucia Totanes. A copy of this report, along with the Licensee Rights (9058 01/16) was emailed to the administrator at the conclusion of the visit, an electronic response confirms the receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Kristina Ryan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC809 (FAS) - (06/04)
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