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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800174
Report Date: 10/07/2021
Date Signed: 10/07/2021 02:51:07 PM

Document Has Been Signed on 10/07/2021 02:51 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:DAVIS CARE SERVICES INCFACILITY NUMBER:
331800174
ADMINISTRATOR:MCCOY JR, WILLIAMFACILITY TYPE:
735
ADDRESS:40927 BELLERAY AVETELEPHONE:
(951) 239-0996
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 4CENSUS: 4DATE:
10/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Facility Manager Hoang Truong TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Facility Manager Hoang Truong and explained the purpose of the visit. At the time of visit there were 2 staff and 4 residents present. The facility currently has zero positive or suspected Covid-19 cases. Prior to LPAs visit, LPA completed the COVID risk assessment.

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 posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer) located in each bathroom and throughout the facility. Staff were also observed wearing appropriate face coverings (cloth masks).

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks two times daily. Each facility staff cleans and disinfects the highly touched surfaces three times a day. Staff also report that the facility is deep cleaned daily during each NOC shift.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to Facility Manager Hoang Truong.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2021
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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