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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604485
Report Date: 10/11/2022
Date Signed: 10/11/2022 01:03:02 PM

Document Has Been Signed on 10/11/2022 01:03 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:POWAY ELDER CAREFACILITY NUMBER:
374604485
ADMINISTRATOR:RATHI, GAURAVFACILITY TYPE:
740
ADDRESS:14846 ESPOLA RDTELEPHONE:
(419) 377-9822
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 6DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Nikita Mundhada, AdministratorTIME COMPLETED:
11:42 AM
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced annual required inspection on today's date. LPA was greeted at the front door and granted entry by Claudia Lizardgo, caregiver, after identifying herself and disclosing the purpose of the visit. An overall tour of the facility was conducted. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other requirements most relevant to protecting the health of residents in care and staff, including in the area of infection control practices. Nikita Mundhada, Administrator, arrived after the tour

LPA reviewed with TITLE the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC808) including the following sections: Persons in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility Plans for Infection Control, and Physical Distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; a sign-in policy enacted for all visitors; signs posted at facility 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; a designated visitation area; and an adequate supply of PPE (Personal Protective Equipment).

Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC808. Technical assistance was given regarding mask wearing for staff. Technical violation was given for having cleaning products accessible to residents. An exit interview was conducted with Administrator and a copy of this report along with Licensee/Appeal Rights (LIC9058) were provided.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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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