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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880717
Report Date: 06/21/2022
Date Signed: 06/21/2022 01:05:55 PM


Document Has Been Signed on 06/21/2022 01:05 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:FAIRHILL ELDER CAREFACILITY NUMBER:
331880717
ADMINISTRATOR:MANAHAN, GLYKA NICOLEFACILITY TYPE:
740
ADDRESS:31012 FAIRHILL CTTELEPHONE:
(951) 246-0597
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY:6CENSUS: 6DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:Staff- Barbara BalisiTIME COMPLETED:
01:10 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 met with staff Shirley Cervantes, who was informed of the purpose of the visit. At the time of visit there was 2 staff and 6 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 that the facility has implemented. LPA observed Covid-19 postings at the facility and a single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all 2 restrooms. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces.

There were no deficiencies noted at the time of the visit. Advisory notes were documented on LIC9102TA and LIC9102TV forms. An exit interview was conducted, and a copy of this report along with advisory notes was reviewed and provided to facility staff, Barbara Balisi .
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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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