331800064-10-20-2022-18-AS-JARA-CKDPP5-20221020112858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800064
Report Date: 10/20/2022
Date Signed: 10/20/2022 11:29:05 AM

Document Has Been Signed on 10/20/2022 11:29 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:	SACRED HEART-STOYVIEW		FACILITY NUMBER:	331800064
ADMINISTRATOR:	CERDA, YAZMIN		FACILITY TYPE:	740
ADDRESS:	37189 STOYVIEW CIRCLE		TELEPHONE:	(951) 698-4258
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY:	6	CENSUS: 3	DATE:	10/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Administrator Yazmin Cerda		TIME COMPLETED:	11:35 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit on 10/20/2022 at 9:12 a.m. in order to conduct an annual visit with a focus on infection control. LPA met with administrator, Yazmin Cerda, who was informed of the purpose of the visit. At the time of the visit there were (2) staff and (3) residents present. LPA proceed to conduct a walk through of the facility's interior and exterior. LPA observed there was a central entry point where screenings are conducted for facility visits. LPA observed COVID-19 postings throughout the facility. The facility has a 30-day supply of PPE equipment that is readily accessible to staff. The facility has a designated visitation area in the facility. LPA observed the vacant bedroom that would be used as an isolation room. The resident bathrooms were observed to be clean and have the appropriate hand hygiene supplies such as hand sanitizer, soap, running water and paper towels. The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility and the isolation rooms. The staff have leave in case of contact or testing positive for COVID-19. The staff have been trained on how to properly don and doff the PPE equipment, and there is a plan of care in place to attend to those residents that would be in the isolation rooms. The staff have also been FIT tested for an N95 respiratory. LPA noted that staff 1 (S1) and staff 2 (S2) were not listed on the staff roster on Guardian, but where listed on the LIC500 at the facility. Administrator stated that the staff were cleared and that the administrator had transferred them to the facility roster. LPA reviewed the documentation for S1 and S2 and verified clearance numbers for both staff. LPA reviewed documentation of staff being associated to the roster. LPA will document this on an advisory note to have administrator resend transfer sheets to LPA by tomorrow 10/21/2022 close of business.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SACRED HEART-STOYVIEW	FACILITY NUMBER: 331800064
	VISIT DATE: 10/20/2022

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Technical advisory note will be documented for the facility not having an updated LIC9020. LPA observed (2) residents were listed and the facility currently relocated a resident the night prior making the census (3). The administrator shall send this updated form to LPA by tomorrow close of business 10/21/2022 5:00 p.m.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where this report was reviewed and provided to administrator, Yazmin Cerda.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC809 (FAS) - (06/04)

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