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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604362
Report Date: 06/17/2022
Date Signed: 06/17/2022 10:04:53 AM

Document Has Been Signed on 06/17/2022 10:04 AM - 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:UC CARE SENIOR LIVING IIFACILITY NUMBER:
374604362
ADMINISTRATOR:KELLY, FLORAFACILITY TYPE:
740
ADDRESS:3739 MILLIKIN AVETELEPHONE:
(858) 203-1160
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY: 6CENSUS: 6DATE:
06/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator, Flora KellyTIME COMPLETED:
10:10 AM
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, Sabel Martinez, and the County of San Diego Nurse, Robert Montilano, with the HAI Program, conducted an on-site visit. The team identified themselves and discussed the purpose of the visit with Administrator, Flora Kelly.

The Department and HAI Team conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment. During today's visit, the team conducted a walk-through of the facility. A debriefing was conducted with the administrator at the conclusion of the visit. During today's visit, no deficiencies were issued.

An exit interview was conducted with Administrator, Kelly Flora, to whom a copy of this report and Licensee Rights (LIC 9058 01-2016) were provided to.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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