331880819-4-20-2022-18-AS-JARA-CDMTNB-20220419145229

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880819
Report Date: 04/19/2022
Date Signed: 04/20/2022 04:25:13 PM

Document Has Been Signed on 04/20/2022 04:25 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:	CALEB HOME		FACILITY NUMBER:	331880819
ADMINISTRATOR:	SAMANTHA PADILLA		FACILITY TYPE:	735
ADDRESS:	49252 PLUMA VERDE PLACE		TELEPHONE:	(760) 601-7307
CITY:	COACHELLA	STATE: CA	ZIP CODE:	92236
CAPACITY: 4		CENSUS: 4	DATE:	04/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:46 PM
MET WITH:	Administrator- Samantha Padilla		TIME COMPLETED:	03:00 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), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Administrator, Samantha Padilla, who was informed of the purpose of the visit. At the time of visit there were 3 staff and 4 residents present. The facility currently has zero positive or suspected Covid-19 cases. During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings throughout the facility. A single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. Common areas such as dinning rooms and activity rooms have been modified with social distancing and masking policies. There is a plan in place to isolate suspected and confirmed COVID-19 cases. LPA was informed of staff training in the proper use of PPE equipment, and observed a sufficient 30-day supply. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

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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Document Has Been Signed on 04/20/2022 04:25 PM - It Cannot Be Edited

Created By: Janira Arreola On 04/19/2022 at 02:30 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: CALEB HOME	FACILITY NUMBER: 331880819
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

3205(c)(5)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with Facility administrator Samantha Padilla, the licensee did not comply with the section cited above with facility staff not being N95 Fit tested. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/27/2022
	Plan of Correction
1 2 3 4	Licensee will ensure all current and future staff are tested for N95 masks and will submit proof to LPA by the POC date. Licensee shall also review the appropraite PIN as part of the Plan of Correction.

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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janira Arreola

LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CALEB HOME	FACILITY NUMBER: 331880819
	VISIT DATE: 04/19/2022

NARRATIVE

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LPA along with Administrator noticed the following areas needing repair:

· Dresser in R1’s room down stairs was observed to be damaged and cleared out for removal. Administrator cleared dresser from R1’s room by the end of the visit.

· Holes in R1’s room where observed on the wall, as well as under the kitchen island.

· Screen door leading to patio was ripped and set aside for repair.

· Patio umbrella was observed to be broken and next to resident seating area in the backyard. Staff cleared umbrella away from resident seating area by the end of the visit.

Administrator provided LPA with work orders for all the items above and documented these on an LIC 9102TA and LIC 812.

LPA along with Administrator noticed the following deficiencies:

· Facility staff have not been provided with N95 fit testing. This is a failure to comply with Cal/OSHA COVID-19 Prevention ETS, at Title 8 CCR, section 3205(c)(5). For this, a Type B deficiency will be issued.

An exit interview was conducted, and a copy of this report, LIC 9102TA, LIC 809 D, and appeal rights were reviewed and provided to facility administrator, Samantha Padilla.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC809 (FAS) - (06/04)

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