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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604421
Report Date: 03/03/2022
Date Signed: 03/09/2022 09:21:41 AM

Document Has Been Signed on 03/09/2022 09:21 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:LA JOLLA VISTAFACILITY NUMBER:
374604421
ADMINISTRATOR:FERNANDEZ, GUSFACILITY TYPE:
740
ADDRESS:5720 DESERT VIEW DRTELEPHONE:
(858) 775-6935
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY: 6CENSUS: 2DATE:
03/03/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Co-Administrator Jennifer FernandezTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Liliana Silveira, and County of San Diego Public Health Nurses Jennifer West and Elizar Perez, with the Healthcare-Associated Infections (HAI) Program, conducted an on-site HAI assessment visit. LPA and Public Health Nurse identified themselves and discussed the purpose of the visit with Co-Administrator Jennifer Fernandez.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan to include disinfection, testing, vaccination, and screening protocols as well as the use of personal protective equipment (PPE). During today's visit, LPA and team conducted a walk-though of the facility. A debriefing was conducted with Jennifer at the conclusion of the visit.

No deficiencies were cited during today's visit. An exit interview was conducted with Jennifer, and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrators via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
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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