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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800081
Report Date: 05/16/2022
Date Signed: 05/16/2022 12:47:35 PM


Document Has Been Signed on 05/16/2022 12:47 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:BUSMAN RESIDENTIAL CARE LLCFACILITY NUMBER:
331800081
ADMINISTRATOR:READE, JOHNFACILITY TYPE:
740
ADDRESS:27892 BUSMAN ROADTELEPHONE:
(951) 888-9512
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 5DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Licensee- John ReadeTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by S1 and met with Licensee John Reade, who was informed of the purpose of the visit. At the time of visit there were 3 staff and 5 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings at the facility and advised licensee to post them throughout the facility. A single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. LPA advised licensee to start documenting these temperatures and to have a sign in sheet for visitors. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. LPA advised licensee to place soap in down stairs bathroom. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA observed a sufficient 30-day supply of PPE equipment. LPA advised Licensee to have staff FIT tested for the N95 masks. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
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: BUSMAN RESIDENTIAL CARE LLC
FACILITY NUMBER: 331800081
VISIT DATE: 05/16/2022
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During the tour of the facility LPA reviewed LIC9020 and advised Licensee to update this after R1 passed away. LPA received a copy of the death report that was e-mailed the the department within 7 days. LPA also advised Licensee to e-mail updated LIC500 as soon as possible. LPA was able to review e-mail from Administration Certification department for Administrator Certification renewal. LPA spoke with Department representative Roshika, and confirmed this information.

There were no deficiencies noted at the time of the visit.

An exit interview was conducted, and a copy of this report was reviewed and provided to facility licensee, John Reade.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
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