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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602023
Report Date: 08/02/2022
Date Signed: 08/02/2022 03:19:18 PM

Document Has Been Signed on 08/02/2022 03:19 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: 4CENSUS: 4DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Caroline Belarmino, Caregiver, and Licensee Jesusa PascuaTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself and was granted entry by Caroline Belarmino, caregiver. LPA met with caregiver Belarmino and discussed the purpose of today’s visit. Licensee Jesusa Pascua later arrived and joined the visit.

A tour of the facility was conducted inside and out. LPA accompanied by caregiver Belarmino conducted a general overall inspection, with specific focus on infection control protocols.

During today's inspection LPA observations include the following: Symptom screening procedures for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing/hand hygiene practices, cough and sneeze etiquette and other infection control procedures; testing plan and procedures for staff and clients; plans for containing infections, PPE supplies procedures and training; and disinfection procedures. LPA provided updated guidance with current PINs for Coronavirus (COVID-19) Additional Vaccine and Booster Doses; Updated Diagnostic and Response Testing Guidance for COVID-19 with supplemental guidance; and Resident Cohorting, Isolation and Quarantine, Staffing and Use of PPE Based on Resident COVID-19 Status.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Licensee Jesusa Pascua. A copy of this report, along with the Licensee Rights (01/2016) was provided to Licensee Pascua at the conclusion of the visit. The signature below serves as confirmation of receipt of these documents.

LPA requested for Licensee Pascua to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-E to the licensing office within 10 business days. Forms available at www.ccld.ca.gov.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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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