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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880817
Report Date: 05/23/2022
Date Signed: 05/23/2022 11:35:06 AM

Document Has Been Signed on 05/23/2022 11:35 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:LIDNA'S PLACEFACILITY NUMBER:
331880817
ADMINISTRATOR:PINA, LIDIAFACILITY TYPE:
735
ADDRESS:28413 CALLE DE REMOTELEPHONE:
(951) 201-7382
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 2CENSUS: 0DATE:
05/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Administrator Lidia PinaTIME COMPLETED:
11:40 AM
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On 05/23/2022. Licensing Program Analyst (LPA) Venus Mixson made an unannounced annual required visit. LPA was greeted and granted entry by Administrator Lidia Pina. LPA Mixson introduced self and explained the purpose of the visit with an emphasis on infection control. LPA was given tour of facility by Administrator.
Present in the facility were no clients residing at the facility and 2 caregivers. There are currently no cases of COVID-19 within the facility.

LPA Mixson toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions and the proper 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, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities. LPA later discussed infection control practices and procedures with Administrator. There were no signs posted outside of isolation rooms to indicate appropriate contact and respiratory droplet precautions. Licensee has not provided all staff who are working with COVID-19 positive residents with fit testing for N95 respirators. A Technical Advisory (TA) was provided to further explain the requirement.

An exit interview was conducted, and a copy of this report, along with the LIC9102 TA.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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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