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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880710
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:54:42 PM

Document Has Been Signed on 05/12/2022 12:54 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:BALLENTINE RESIDENTIAL CAREFACILITY NUMBER:
331880710
ADMINISTRATOR:RYAN SHERMANFACILITY TYPE:
735
ADDRESS:40154 TENNYSON RDTELEPHONE:
(951) 397-3916
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 4CENSUS: 4DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Licensee- Allison ShermanTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was granted entry by staff member Leon Colina. LPA met with Administrator Allison Sherman and Licensee Ryan Sherman, who were informed of the purpose of the visit. At the time of visit there was 3 staff and 4 residents present. 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. LPA was able to review facility mitigation plan at the facility. LPA advised Licensee to post Covid-19 postings at the facility. A single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors and staff. LPA will give a technical violation due to facility not doing symptoms screenings for residents since March 2022. The facility had a plan in place to test staff and residents when they experience symptoms of Covid-19. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all 2 restrooms.LPA advised facility to post hand washing posters in both restrooms. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. LPA will give a technical violation due to staff members Ryan, Allison, and Leon not wearing a mask while at the facility. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA will give technical advisory note so staff can start screening residents when they come back to the facility from an outing.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BALLENTINE RESIDENTIAL CARE
FACILITY NUMBER: 331880710
VISIT DATE: 05/12/2022
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LPA observed a sufficient 30-day supply of PPE equipment. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces.

LPA spoke with Administrator about S1 who currently is "in process" with her fingerprints. LPA advised Licensee to access the Guardian website to make sure staff gets cleared before starting work. LPA will give technical violation for facility not having a current LIC9020 and LIC500 on file.

An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee, Ryan Sherman.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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