<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880742
Report Date: 05/11/2022
Date Signed: 05/11/2022 04:48:57 PM

Document Has Been Signed on 05/11/2022 04:48 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:A HOME 4 WAYNE, INC.FACILITY NUMBER:
331880742
ADMINISTRATOR:WATSON, PAMELAFACILITY TYPE:
735
ADDRESS:621 GROVESIDE DRTELEPHONE:
(951) 219-2467
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 6CENSUS: 4DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:James Willis, House LeadTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 2:15 PM, LPA was met by House Lead James Willis and explained the purpose of the visit. Present in the facility during time of visit were four (4) staff as well as four (4) residents. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed insufficient signage throughout the facility, insufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and no use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, additional PPE supplies need to be maintained at the facility, cleaning and disinfection provisions are in inadequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also needs to maintain a plan to monitor resident(s) and staff regularly for any changes in condition and to subsequently notify the resident(s) physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, one (1) Technical Advisory and one (1) deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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 3
Document Has Been Signed on 05/11/2022 04:48 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 05/11/2022 at 04:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A HOME 4 WAYNE, INC.
FACILITY NUMBER: 331880742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
Personal rights: (a) Except for children's residential facilities, each client shall have personal rights which include but are not limited to, the following: (2) To be accorded safe, healthful, and comfortable accomodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
LPA Delgado observed the licensee did not comply with the section cited above, did not ensure COVID-19 Infection Control measures: COVID-19 screening protocols and practices for all staff, residents and visitors. The personal rights of persons in care to safe and healthful to the health, welfare, and safety of persons in care, as required by the CA Dept. of Public Health Guidance. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2022
Plan of Correction
1
2
3
4
The licensee will obtain additional PPE supplies, comply screening protocols and practice. Proof of correction will be submitted to LPA Delgado by 5pm on POC.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3