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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880747
Report Date: 08/17/2021
Date Signed: 08/17/2021 12:56:25 PM

Document Has Been Signed on 08/17/2021 12:56 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:CHIHUAHUA HOMEFACILITY NUMBER:
331880747
ADMINISTRATOR:WEST COAST CARE PROVIDERSFACILITY TYPE:
735
ADDRESS:77595 CALLE CHIHUAHUATELEPHONE:
(442) 256-4174
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY: 4CENSUS: 4DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:54 AM
MET WITH:Ignacio CoronaTIME COMPLETED:
12:59 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for the purpose of conducting an required annual visit, with emphasis on infection control. LPA was greeted and temperature taken at the door by DSP, Ignacio Corona. LPA explained the purpose of today's visit and toured the inside and outside of the facility.

During today’s visit, LPA made observations pertaining to the facility’s infection control measures. LPA observed sufficient hand hygiene supplies and sufficient cleaning and disinfecting provisions. LPA observed COVID-19 signages around the facility, including near sinks. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in 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 clients for COVID-19, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

A technical advisory was noted regarding the combination light and fan fixture in bedroom 1, where the string to turn the light on is broken. Anexit interview was conducted, and a copy of this report was provided to Mr. Corona
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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