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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880632
Report Date: 02/09/2022
Date Signed: 02/22/2022 03:15:46 PM


Document Has Been Signed on 02/22/2022 03:15 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
RIVERSIDE, CA 92507



FACILITY NAME:MIRA LOMA SENIOR CAREFACILITY NUMBER:
331880632
ADMINISTRATOR:DHUNNA, RAJNISH KFACILITY TYPE:
740
ADDRESS:12400 DAKOTA RIVER CTTELEPHONE:
(951) 444-6661
CITY:EASTVALESTATE: CAZIP CODE:
91752
CAPACITY:6CENSUS: 4DATE:
02/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Amy Goldenberg made an announced 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 was met at the door by a caregiver and granted entry into the home. They are wearing a mask. 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 will temperature screening visitors upon entry into the facility. LPA is informed that there are currently three (3) residents in the home.

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 have 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.

Based on observations made during today’s inspection, there are no deficiencies 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) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
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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