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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601693
Report Date: 05/26/2022
Date Signed: 05/26/2022 09:08:29 PM

Document Has Been Signed on 05/26/2022 09:08 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:PEPPERTREE GUEST HOME IIFACILITY NUMBER:
374601693
ADMINISTRATOR:MARIO G. CAGAYATFACILITY TYPE:
740
ADDRESS:8950 JOHNSON DRIVETELEPHONE:
(619) 460-8155
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 6CENSUS: 5DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Cherrylin Sanosa, Assistant Administrator.TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced Required 1 -Year Visit. LPA identified herself and was allowed entry to the facility by Caregiver Izzyl Delossantos. LPA met with Cherrylin Sanosa, Assistant Administrator and discussed the purpose of the visit.

LPA conducted a tour of the facility with Cherrylin Sanosa, Assistant Administrator. In accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; A sign-in policy enacted for all visitors; 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 PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit.

An exit interview was conducted with Assistant Administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 01/16) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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