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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800444
Report Date: 05/24/2022
Date Signed: 06/29/2022 10:12:32 AM

Document Has Been Signed on 06/29/2022 10:12 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:VIDA HOME SERVICES INCFACILITY NUMBER:
331800444
ADMINISTRATOR:BESINA JR, AURELIOFACILITY TYPE:
735
ADDRESS:983 SAW TOOTH LANETELEPHONE:
(562) 569-8115
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 5CENSUS: 0DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Assistant Administrator Cheryl BalquiedraTIME COMPLETED:
12:15 PM
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On 05/24/2022, Licensing Program Analyst (LPA), Venus Mixson arrived at the above facility for an announced required annual with an emphasis on infection control. LPA Mixson was greeted and granted entry by Administrator, Cheryl Balquiedra. LPA Mixson introduced self and explained the purpose of the visit, and was given a tour of the facility by Administrator.

There are currently no cases of COVID-19 within the facility, and no clients residing in the home.

LPA Mixson toured the facility and made observations pertaining to the facility's infection control measures. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions and the proper use of face coverings.

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, and cleaning and disinfection provisions are in adequate quantities. LPA Mixson later discussed infection control practices and procedures with Administrator.

An exit interview was conducted, and a copy of this report was provided to Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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