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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800454
Report Date: 11/04/2022
Date Signed: 11/04/2022 11:38:30 AM

Document Has Been Signed on 11/04/2022 11:38 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:FAITHWORKS RESIDENTIAL HOMESFACILITY NUMBER:
331800454
ADMINISTRATOR:GROVE, ZENOBIAFACILITY TYPE:
735
ADDRESS:31922 BAY LAUREL STREETTELEPHONE:
(951) 430-1429
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 4CENSUS: DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Staff Mary SmithTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit on 11/04/2022 at 10:20 a.m. in order to conduct an annual visit with a focus on infection control. LPA met with staff, Mary Smith, who was informed of the purpose of the visit. LPA spoke with the administrator over the phone, Zenobia Grove and asked additional questions. At the time of the visit there were (2) staff and (2) residents present.

LPA proceed to conduct a walk through of the facility's interior and exterior. LPA observed there was a central entry point where screenings are conducted for facility visits. LPA observed COVID-19 postings throughout the facility. The facility has a 30-day supply of PPE equipment that is readily accessible for residents and staff. The facility has a designated visitation area in the facility. LPA observed the resident bedrooms that would be used as isolation rooms. The resident bathrooms were observed to be clean and have the appropriate hand hygiene supplies such as hand sanitizer, soap, running water and paper towels.

The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility and the isolation rooms. The staff have leave in case of contact or testing positive for COVID-19. The staff have been trained on how to properly don and doff the PPE equipment, and there is a plan of care in place to attend to those residents that would be in the isolation rooms. The staff have also been FIT tested for an N95 respiratory.

LPA will document technical advisory for the facility to send over the infection control plan to LPA and Monkey pox infection control plan. The administrator will send the plan to LPA by the end of the day today 11/04/2022. LPA documented technical advisory note for gardening storage bin that was unlocked. No clients were in the yard at the time LPA observed this was open and the staff was able to secure the bin with a lock immediately.

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided to staff Mary Smith.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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