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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880799
Report Date: 09/17/2021
Date Signed: 09/24/2021 12:18:44 PM

Document Has Been Signed on 09/24/2021 12:18 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:WOLF CREEK RESIDENCEFACILITY NUMBER:
331880799
ADMINISTRATOR:MANALANSAN, SUZETTEFACILITY TYPE:
735
ADDRESS:45561 JAGUAR WAYTELEPHONE:
(951) 240-7189
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY: 6CENSUS: 1DATE:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Suzette Manalansan, AdministratorTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Stephanie Torres made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. The LPA was met by Administrator, Suzette Manalansan, and informed her of the purpose of the visit. There are currently no cases of COVID-19 within the facility.

During today's visit, LPAs toured the facility and made observations pertaining to the facility's infection control measures. LPAs observed sufficient hand hygiene supplies and sufficient cleaning and disinfecting provisions. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate 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 has a plan in place to monitor residents 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, no 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: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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