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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880616
Report Date: 11/04/2021
Date Signed: 11/04/2021 11:21:06 AM

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:ANNA CARE LLCFACILITY NUMBER:
331880616
ADMINISTRATOR:BLANCAFLOR, ANNALISAFACILITY TYPE:
740
ADDRESS:26461 RIDGEMOOR RDTELEPHONE:
(909) 231-5700
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY:6CENSUS: 5DATE:
11/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Antonio Fajardo CaregiverTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Caregiver Antonio Fajardo. LPA explained the purpose of the visit. Administrator was unavailable, as she is home recovering from a procedure. At the time of visit there were 2 staff and 5 residents present. Prior to LPAs visit LPA completed the Covid-19 risk assessment with Licensee/Administrator. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer). Staff were also observed wearing appropriate face coverings (surgical masks).

The facility completes daily temperature checks ,two times a day which assist with monitoring residents regularly for any changes in condition. Should there be any changes or Covid-19 related symptoms with any resident(s), the facility will contact the resident's physician. Per the facility mitigation plan the facility has a total of designated infection control leads (LVN, and Administrator). All facility staff are responsible for cleaning and disinfecting the highly touched surfaces multiple times throughout the day.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to Caregiver Antonio Fajardo.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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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