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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602023
Report Date: 07/27/2021
Date Signed: 07/27/2021 02:19:26 PM

Document Has Been Signed on 07/27/2021 02:19 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:PASCUA RCFEFACILITY NUMBER:
374602023
ADMINISTRATOR:JESUSA PASCUAFACILITY TYPE:
740
ADDRESS:1268 STAMEN STTELEPHONE:
(619) 266-0179
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 6CENSUS: 2DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Merlita Simeon, CaregiverTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Daniel Pena visited the facility to conduct an annual required licensing inspection. LPA was met by Caregiver, Merlita Simeon and was granted entry into the facility and discussed the purpose of the visit. Administrator, Jesusa Pascua, later met with LPA to review the facility's Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report and protocols.

During today's visit, LPA toured the facility, and verified compliance with infection control practices. LPA and Caregiver Simeon reviewed the facility’s COVID-19 Mitigation Plan Report and staff practices. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs 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; 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 cleaning products and PPE.

No deficiencies were cited during today’s visit. An exit interview was conducted with Administrator Pascua and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to Ms. Pascua via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2021
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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