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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800178
Report Date: 08/25/2021
Date Signed: 08/25/2021 11:08:34 AM

Document Has Been Signed on 08/25/2021 11:08 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:THAVMA HOMEFACILITY NUMBER:
331800178
ADMINISTRATOR:SAMSON, MILAGROS VFACILITY TYPE:
735
ADDRESS:6775 MONARCH WAYTELEPHONE:
(951) 934-3563
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY: 4CENSUS: 4DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Milagros SamsonTIME COMPLETED:
11:23 AM
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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 Milagros Samson and advised her 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 Ms. Samson who is 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 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. LPA observed a cart that will be used as a PPE isolation cart. LPA inquired as to if staff have been fit tested for N95 masks, and Ms. Samson stated that staff have been fit tested and presented documents to verify.

An exit interview was conducted, and this report was discussed and provided to Ms. Sampson.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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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