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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880524
Report Date: 11/22/2022
Date Signed: 11/22/2022 11:55:52 AM

Document Has Been Signed on 11/22/2022 11:55 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:CHAP RESIDENTIAL CARE FACILITYFACILITY NUMBER:
331880524
ADMINISTRATOR:CHAP, SOKHEAFACILITY TYPE:
735
ADDRESS:29484 CAMINO CRISTALTELEPHONE:
(951) 443-5087
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 4CENSUS: 3DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Licensee, Sokeah ChapTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit on 11/22/2022 at 10:45 a.m. in order to conduct an annual visit with a focus on infection control. LPA met with Licensee, Sokeah Chap, who was informed of the purpose of the visit. At the time of the visit there were (2) staff and (1) 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, staff, and residents. LPA observed COVID-19 postings at the facility. The facility has a 30-day supply of PPE equipment that is readily accessible for residents and staff. The staff have been trained on how to properly don and doff the PPE equipment. LPA observed the resident bedrooms that would be used as isolation rooms. There is a plan of care in place to attend to those residents that would be in the isolation rooms. The resident bathrooms were observed to be clean and have the appropriate hand hygiene supplies. The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility. The staff have leave in case of contact or testing positive for COVID-19.

LPA was informed by licensee that staff have not been FIT tested for an N95 respiratory. LPA will document this on a technical advisory note. LPA also advised Licensee to have a LIC9020 on file for the residents. The licensee was able to complete this by the end of the visit. This will be documented on a technical advisory note. LPA observe the shed with gardening tools in the backyard had a piece of wood holding the doors shut. LPA advised the licensee to obtain a lock to secure the shed. This will be documented on a technical advisory note.

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided to Licensee, Sokeah Chap
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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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