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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800088
Report Date: 02/15/2022
Date Signed: 02/15/2022 12:49:55 PM

Document Has Been Signed on 02/15/2022 12:49 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:STEWART'S RESIDENTIAL CAREFACILITY NUMBER:
331800088
ADMINISTRATOR:STEWART, REUBENFACILITY TYPE:
735
ADDRESS:3631 MARI DRIVETELEPHONE:
(562) 682-0946
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 4DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Adegboyega AgbelusiTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Jennifer Semin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility via telephone. LPA met with administrator Adegboyega Agbelusi and advised him of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only.
LPA went over COVID-19 best practices for infection control and prevention with the administrator who are successfully incorporating the facility's Mitigation Plan. Clients have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA observed the facility to have multiple postings throughout the facility and for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for local fire department has been updated.
LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the central entry point for convenience. LPA observed a storage area for storing all PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer supply and is inaccessible to clients. A Technical Assistance Advisory note is being issued as licensees need to procure additional PPE. LPA and administrator discussed creating a box, or similar, to have a supply of PPE ready that would be dedicated for isolation room, along with a trash can to put inside and outside of an isolation room.
LPA inquired as to if staff have been fit tested for N95 masks, and administrator stated he has been fit tested but the staff have not been fit tested yet. LPA will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results.
LPA provided administrator with the Provider Information Notice (PIN) PIN-21-10-ASC information which contains resources for getting staff fit tested for N95 masks.
An exit interview was conducted, and this report was discussed and provided to Mr. and administrator along with LIC9102 TA Advisory Notes.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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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