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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800234
Report Date: 08/29/2022
Date Signed: 08/29/2022 12:29:26 PM


Document Has Been Signed on 08/29/2022 12:29 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
, CA 92507



FACILITY NAME:EAGLE GLEN CARE HOME INCFACILITY NUMBER:
331800234
ADMINISTRATOR:RESTITUTO L. CALILUNGFACILITY TYPE:
740
ADDRESS:1697 HONORS CIRCLETELEPHONE:
(714) 906-6046
CITY:CORONASTATE: CAZIP CODE:
92883
CAPACITY:6CENSUS: 6DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Dave Mendoza, CaregiverTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (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. LPA observes that all staff are wearing face masks. LPA is informed that there are no COVID positive individuals in the home. 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 will occur. The staff are temperature screening visitors upon entry into the facility. LPA is informed that there are currently six (6) residents in the home three (3) of which are receiving hospice care.

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 has a limited supply of Personal Protective Equipment (PPE). LPA discussed the availability of additional PPE supplies to the facility at the time of this visit and advised the facility representatives to contact our office in the event additional supplies are necessary.

LPA is unable to review employee records. Caregiver disclosed that they had not been fit tested for N95. Based on observations made during today’s inspection, the following deficiency is being 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: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
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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Document Has Been Signed on 08/29/2022 12:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: EAGLE GLEN CARE HOME INC
FACILITY NUMBER: 331800234

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87209


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on telephone call with the licensee, the licensee did not comply with the section cited above in that there are no employee records available at the facility on this date for LPA to review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2022
Plan of Correction
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Licensee to provide the requested records for LPA to review by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
LIC809 (FAS) - (06/04)
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