<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800230
Report Date: 09/08/2022
Date Signed: 09/08/2022 11:40:47 AM


Document Has Been Signed on 09/08/2022 11:40 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
, CA 92507



FACILITY NAME:CRESENCIA CARE HOME INCFACILITY NUMBER:
331800230
ADMINISTRATOR:CALILUNG, RESTITUTO LFACILITY TYPE:
740
ADDRESS:1785 HONORS LNTELEPHONE:
(714) 906-6046
CITY:CORONASTATE: CAZIP CODE:
92883
CAPACITY:6CENSUS: 5DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:TIME COMPLETED:
11:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) Amy Goldenberg made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. The facility has an approved mitigation plan on file with this agency. Precautionary Covid-19 postings are present at the front door and at the entry point. There is one entry point designated where sign in procedures and screening occur. The staff are symptom/temperature screening visitors upon entry into the facility. LPA observes that all staff are wearing face masks. LPA is informed that there are no positive cases of Covid-19 at this time. There are five (5) residents present at the time of the visit, of which four (4) are receiving hospice services.

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and a 30 day supply of Personal Protective Equipment (PPE). 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 infection control. The facility continues to monitor client regularly for any changes in condition, and notify the client's physician and emergency personnel in the event the client presents any COVID-19 symptoms. Emergency food supply is in place. LPA inquired about fit testing and found that the employees have not been fit tested for N95 respirators. Technical assistance provided during this visit.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2