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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603769
Report Date: 04/26/2021
Date Signed: 04/26/2021 02:13:02 PM

Document Has Been Signed on 04/26/2021 02:13 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:LIFE SAVER PLACE OF ESCONDIDOFACILITY NUMBER:
374603769
ADMINISTRATOR:BALANQUIT, IEZLFACILITY TYPE:
740
ADDRESS:2234 CORTINA CIRCLETELEPHONE:
(858) 284-9114
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY: 6CENSUS: 6DATE:
04/26/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Iezl BalanquitTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Eva Torres conducted a virtual case management visit via FaceTime to review and discuss the Mitigation Plan, as well as provide technical assistance surrounding COVID-19. LPA identified herself and discussed the purpose of the conference call with Administrator, Iezl Balanquit

During the virtual visit, LPA reviewed the Mitigation Plan with Mr. Balanquit and provided consultation while evaluating the facility's staffing plan, surveillance testing, and screening protocols, as well as the use of personal protective equipment (PPE). LPA also inspected the facility’s screening areas, disinfectant supply, and their PPE reserve.

An exit interview was conducted with Mr. Balanquit and a copy of this report, along with Licensee Rights (LIC 9058 01/16), was emailed to them. A reply email or return receipt from the Mr. Balanquit will confirm receipt of documents.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2021
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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