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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800154
Report Date: 05/13/2022
Date Signed: 05/13/2022 12:26:10 PM

Document Has Been Signed on 05/13/2022 12:26 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:CASA ALISAFACILITY NUMBER:
331800154
ADMINISTRATOR:ALCOCER, PETER KFACILITY TYPE:
735
ADDRESS:15849 ALISA VIEJO COURTTELEPHONE:
(714) 448-0533
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 4DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Peter Alcocer, AdministratorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA arrived at approximately 11:40 AM. The LPA met with Administrator, Peter Alcocer, and informed him of the purpose of her visit. There are currently no cases of COVID-19 within the facility.

During today's visit, the LPA toured the home and made observations pertaining to the facility's infection control measures. The LPA observed sufficient hand hygiene supplies and sufficient cleaning and disinfecting provisions. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place with Community Care Licensing for when and how long to test staff and clients for COVID-19, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, Chapter 1 or 6 of the California Code of Regulations. An exit interview to review this report was conducted with Alcocer and a copy of this report was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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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