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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604063
Report Date: 08/08/2022
Date Signed: 08/08/2022 01:42:43 PM

Document Has Been Signed on 08/08/2022 01:42 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:MESAVIEW SENIOR ASSISTED LIVINGFACILITY NUMBER:
374604063
ADMINISTRATOR:GENOVEVA GUERREROFACILITY TYPE:
740
ADDRESS:7971 CULOWEE STREETTELEPHONE:
(619) 466-0253
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY: 30CENSUS: 28DATE:
08/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Genoveva Guerrero, AdministatorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified himself to, and discussed the purpose of the visit with Administrator Genoveva Guerrero.

LPA conducted a brief tour of the facility and observed the residents in care. In accordance with the Department’s Infection Control, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, screening protocols, and the use of personal protective equipment. No deficiencies were cited on this date.

An exit interview was conducted with Genoveva Guerra, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
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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