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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604393
Report Date: 02/15/2022
Date Signed: 02/16/2022 06:30:31 AM

Document Has Been Signed on 02/16/2022 06:30 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:WELLSPRING ASSISTED LIVING IIFACILITY NUMBER:
374604393
ADMINISTRATOR:MCCLURE, WILLIAMFACILITY TYPE:
740
ADDRESS:7010 JACKSON DRIVETELEPHONE:
(619) 884-7227
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 6CENSUS: 6DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee Jill McClureTIME COMPLETED:
02:00 PM
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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 Licensee Jill McClure identified herself and was granted entry into the facility.

During today's visit, LPA Correia, accompanied by the Licensee McClure, toured the facility and verified compliance with infection control practices. LPA Correia and the licensee 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 the 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: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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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