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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601302
Report Date: 10/19/2021
Date Signed: 10/19/2021 03:48:43 PM

Document Has Been Signed on 10/19/2021 03:48 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:MISSION HOME IIIFACILITY NUMBER:
374601302
ADMINISTRATOR:CURMAK, CERENFACILITY TYPE:
740
ADDRESS:2493 MELBOURNE DRIVETELEPHONE:
(858) 560-7676
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY: 6CENSUS: 6DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Abril Meneses Aguilar and Lidia LeoTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA was allowed entry by, identified herself to, and explained the purpose of the visit to Caregivers Abril Meneses Aguilar and Lidia Leo. Administrator Ceren Curmak was briefly at the facility during the visit.

LPA conducted a brief tour of the facility and observed the clients in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, observed, and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, testing surveillance, screening protocols, and the use of personal protective equipment. No deficiencies were cited or observed on this date.

An exit interview was conducted with Caregiver Lidia Leo. A copy of this report and the licensee appeal rights (LIC9058 01/16) were provided to Administrator Ceren Curmak via E-mail.
SUPERVISORS NAME: Alexandre Vo
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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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