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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601438
Report Date: 08/10/2022
Date Signed: 08/31/2022 01:54:44 PM

Document Has Been Signed on 08/31/2022 01:54 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:DEL CERRO MANOR IIFACILITY NUMBER:
374601438
ADMINISTRATOR:BARTH, BENJAMINFACILITY TYPE:
740
ADDRESS:7232 GLENFLORA AVENUETELEPHONE:
(619) 741-7667
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 6CENSUS: 6DATE:
08/10/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Supervisor Elda AcostaTIME COMPLETED:
04:20 PM
NARRATIVE
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This is an amended version of the Required- 1 year visit conducted on 8/10/2022.

Licensing Program Analyst (LPA) Iby Strong, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Supervisor Elda Acosta and discussed the purpose of the visit.

LPA 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 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.

During visit LPA observed two additional staff at the facility. Neither S1 nor S2 have a criminal background clearance, according to supervisor S1 has been employed since 2/2022 and S2 has been employed for 1 month.

Per Title 22, Division 6, Chapter 8 of the California Code of Regulations, the following deficiency is cited and listed on LIC 809-D. An immediate civil penalty of $1000 was assessed today for Criminal Record Clearance violation on form LIC 421-BG.

The Licensee was provided a copy of their appeal rights (LIC9058 01/16). An exit interview was conducted and a copy of this report was handed to Supervisor Elda Acosta
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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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Document Has Been Signed on 08/31/2022 01:54 PM - It Cannot Be Edited


Created By: Iby Strong On 08/30/2022 at 11:02 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: DEL CERRO MANOR II
FACILITY NUMBER: 374601438

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2022
Section Cited
CCR
87355(e)(1)

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All individuals subject to a criminal record review...prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
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Licensee will provide LPA with a signed statement showing understanding of crimal record clearance regulation by 8/11/2022
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Based on observations and record reviews, the licensee did not comply with the section cited above in 2 out of 3 staff present which poses an immediate health, safety or personal rights risk to persons in care.
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This is an amended version of the Required- 1 year visit conducted on 8/10/2022.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:John Rante
LICENSING EVALUATOR NAME:Iby Strong
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022


LIC809 (FAS) - (06/04)
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