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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604439
Report Date: 06/27/2022
Date Signed: 06/27/2022 12:55:48 PM

Document Has Been Signed on 06/27/2022 12:55 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KELLY'S CEDAR VILLAFACILITY NUMBER:
374604439
ADMINISTRATOR:WELKER, GARRETTFACILITY TYPE:
740
ADDRESS:1341 BOYLE AVENUETELEPHONE:
(619) 504-5049
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 6DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Sheila Clark, CaregiverTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct an annual inspection with emphasis on infection control. LPA met with Caregiver Sheila Clark and explained the purpose of today's visit. LPA spoke with Administrator Garrett Welker and explained the purpose of the visit. Six (6) of six (6) residents were present during LPA's visit.
During today's visit, LPA inspected the facility for regulatory compliance for the mitigation of COVID-19. LPA observed appropriate postings in the facility which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has an approved COVID-19 Mitigation Plan Report (Report) on file which identifies a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and ensures that staff are trained in the facility's infection control measures. The Report also indicates the facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for residents with COVID-19 positive results and/or exposures. Detailed in the Report is a plan to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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