<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602940
Report Date: 11/03/2022
Date Signed: 11/03/2022 02:48:35 PM

Document Has Been Signed on 11/03/2022 02:48 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SERRA MESA GUESTS HOME IIFACILITY NUMBER:
374602940
ADMINISTRATOR:WILFREDO SALAZARFACILITY TYPE:
740
ADDRESS:566 PARKWOOD DRIVETELEPHONE:
(619) 944-3018
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY: 6CENSUS: 4DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Evely Salazar, AdministratorTIME COMPLETED:
02:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Tammer de los Santos and Licensing Program Manager (LPM) Lizzette Tellez, visited the facility to conduct an annual required licensing inspection. LPA and LPM were granted entry into the facility by Celina Samonte, Caregiver and Lolita Tisbe, Assistant Administrator to whom they disclosed the purpose of the visit. Administrator Evelyn Salazar joined a few minutes later.

During today's visit, LPA and LPM toured the facility and verified compliance with infection control practices. LPA and LPM observed one central entry point for universal entry screening; temperature check initiated at entry for staff, residents, and visitors; a sign-in policy enacted for visitors; signs in the facility to promote hand hygiene, cough / sneeze etiquette, symptom and transmission awareness; face coverings worn by staff; hand sanitizer readily available; available visitation area; emergency agencies’ contact information visible to staff; and an ample supply of cleaning products and personal protective equipment.

Administrator previously provided a copy of the completed Infection Control Plan.

No deficiencies were cited during today’s visit. An exit interview was conducted with Evelyn Salazar, Administrator, and copies of this report and Licensee Rights (LIC 9058) were provided to the administrator at the conclusion of the visit. Evelyn Salazar’s signature on this form acknowledges receipt of the rights and a copy of the report.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tammer DeLosSantos
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1