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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330908249
Report Date: 10/19/2021
Date Signed: 10/19/2021 10:01:13 AM

Document Has Been Signed on 10/19/2021 10:01 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PRIOR'S BOARD AND CAREFACILITY NUMBER:
330908249
ADMINISTRATOR:MAE PRIORFACILITY TYPE:
735
ADDRESS:6121 JUPITER DRIVETELEPHONE:
(951) 685-4912
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY: 6CENSUS: 4DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Amy Goldenberg made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA is informed that there are no COVID positive individuals in the home. The facility has an approved mitigation plan on file with this agency. There is screening of visitors upon entry into the facility.

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and has a limited supply of Personal Protective Equipment (PPE). LPA advised the facility representative of the departments availability off PPE and procedure to acquire supplies. The facility continues to monitor client regularly for any changes in condition, and notify the client's physician and emergency personnel in the event the client presents any COVID-19 symptoms.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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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