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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603457
Report Date: 09/14/2021
Date Signed: 09/15/2021 01:17:37 PM

Document Has Been Signed on 09/15/2021 01:17 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:WELLSPRING ASSISTED LIVINGFACILITY NUMBER:
374603457
ADMINISTRATOR:JILL MCCLUREFACILITY TYPE:
740
ADDRESS:6281 JACKSON DRIVETELEPHONE:
(619) 884-7227
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 6CENSUS: 6DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrators', Jill and Scott McClureTIME COMPLETED:
04:30 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) Debbie Correia conducted an unannounced visit to the facility to conduct an annual required licensing inspection. LPA Correia was met by Caregiver Loysa Cisigua, identified herself and was granted entry into the facility. Shortly after facility entry LPA Correia met with Administrators Jill and Scott McClure and explained the purpose of the visit.

During today's visit, LPA Correia, accompanied by the Administrators, toured the facility and verified compliance with infection control practices. LPA Correia and Administrators reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report. LPA Correia 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; hand sanitizer/hand washing stations readily available; 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 Jill McClure and a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to her via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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