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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880778
Report Date: 02/15/2022
Date Signed: 02/15/2022 09:53:29 AM


Document Has Been Signed on 02/15/2022 09:53 AM - 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:FAMILY FIRST RESIDENTIAL CAREFACILITY NUMBER:
331880778
ADMINISTRATOR:FLORES, NIRMLA GFACILITY TYPE:
740
ADDRESS:42299 FABER CTTELEPHONE:
(951) 252-7217
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:6CENSUS: 0DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Nirmla Flores, Administrator TIME COMPLETED:
10:00 AM
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On 02/15/22 Licensing Program Analyst (LPA) Javina George made an announced visit to the facility to conduct an annual inspection focused on infection control. LPA met with Administrator Nirmla Flores. At the time of visit there was 1 staff and 0 residents present, as the facility is currently not operating. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA reviewed the facility's mitigation plan. LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer).

Once the facility resumes operation there is a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to Administrator Nirmla Flores.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
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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