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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603738
Report Date: 07/06/2021
Date Signed: 07/13/2021 02:26:33 PM

Document Has Been Signed on 07/13/2021 02:26 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:NORTH COUNTY COTTAGEFACILITY NUMBER:
374603738
ADMINISTRATOR:MARI DEE SANDRA CIDFACILITY TYPE:
740
ADDRESS:221 W 6TH AVETELEPHONE:
(760) 743-7133
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 13CENSUS: 11DATE:
07/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Mary Laygo TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Eva Torres conducted an unannounced infection control inspection. LPA met with Administrator Mary Laygo. The purpose of today's visit is to inspect and ensure that the facility is following the California Code of Regulations, Title 22, Division 6. The facility is approved for to serve thirteen (13) non-ambulatory elderly residents, ages 60 and above; in which four (4) out of the thirteen (13) may be bedridden. Facility has a hospice waiver for six (6) residents.

Tour included:

Infection Control: LPA reviewed and discussed the Mitigation Plan with the administrator. LPA also provided consultation while reviewing the facility's training records, staffing plan, and screening protocols, including but not limited to inspecting their disinfectant supply and the use of personal protective equipment (PPE). The administrator was advised to remain updated on the changes and directions set forth by the department, so that their COVID’s policy reflects the current information on COVID’s guidelines.

Physical Plant: front entrance, interior, and exterior surroundings were also observed to be clean with no pathway obstruction. The facility does not have firearms and or ammunition on the grounds.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents.

Records: The staff that were present at the facility have a criminal background clearance in file and are associated to the facility. All required postings, including COVID’s postings, were posted near the entrance and throughout the facility. The administrator certificate expires on 09/30/21.

Based on today’s inspection, there were no deficiencies observed per Title 22 Regulation. LPA conducted an exit interview with the administrator. The Licensee Rights (LIC 9058 01/16) and a copy of this report with the administrator's signature on this form was emailed to them. A reply email or return receipt from the administrator will confirm receipt of documents.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2021
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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