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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880840
Report Date: 02/07/2022
Date Signed: 02/07/2022 11:00:45 AM

Document Has Been Signed on 02/07/2022 11:00 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 CARE RETIREMENT HOMEFACILITY NUMBER:
331880840
ADMINISTRATOR:CASTRO, MARY JANEFACILITY TYPE:
740
ADDRESS:69490 MEGAN CTTELEPHONE:
(760) 832-7243
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 6CENSUS: 3DATE:
02/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mary Jane Castro - AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Administrator Mary Jane Castro and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Mary Jane Castro, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels, and hand washing guides are posted near the sinks. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns) which LPA Colvin observed to be sufficient for a 30-day supply. Administrator Mary Jane Castro informed LPA Colvin that the facility is scheduled for automatic monthly deliveries of PPE, so they are never out of any of the supplies and do not have to worry about locating supplies on short notice. LPA Colvin went over the various recommended training for facility staff with Administrator Mary Jane Castro in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Mary Jane Castro confirmed that they have conducted fit testing for all staff. LPA Colvin confirmed through observation that all staff present were wearing face coverings during LPA Colvin's inspection. LPA Colvin was informed that all staff have been vaccinated, so the facility is no longer conducting surveillance testing for COVID-19 for staff. In addition to going over the facility's policy for testing staff and residents for COVID-19, LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2022
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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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: FAMILY CARE RETIREMENT HOME
FACILITY NUMBER: 331880840
VISIT DATE: 02/07/2022
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 Administrator Mary Jane Castro confirmed that staff are continuing to monitor residents’ symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility. The facility staff are additionally informed of the updated visitation guidelines regarding vaccinations and boosters, as well as guests having a negative COVID-19 test, and the facility is keeping record of visitor information to ensure compliance with the State guidelines. LPA Colvin additionally observed a sign-in log for visitors, where their temperature is recorded as well as answers to screening questions.

An exit interview was conducted with Administrator Mary Jane Castro and a copy of this report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
LIC809 (FAS) - (06/04)
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