<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880843
Report Date: 03/17/2022
Date Signed: 03/17/2022 04:24:25 PM

Document Has Been Signed on 03/17/2022 04:24 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:LOVING CAREFACILITY NUMBER:
331880843
ADMINISTRATOR:BUSBY, SYLVIAFACILITY TYPE:
740
ADDRESS:34038 TURTLE CREEK STREETTELEPHONE:
(951) 303-0393
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY: 6CENSUS: 2DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:11 PM
MET WITH:Administrator Sylvia BusbyTIME COMPLETED:
04:30 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
On 3/17/2022 Licensing Program Analysts (LPAs) Javina George and Venus Mixson made an unannounced visit to the above facility to conduct the required one year annual visit. LPA's were greeted and granted entry by Caregiver Alexander Busby. The purpose of the visit was explained to Administrator Sylvia, whom arrived shortly after. LPA's conducted a tour of the facility with an emphasis on infection control. The facility is following covid-19 screening protocol as evidenced by, having the The LPA's signed in, wash their hands and have their temperature taken. There are currently no cases of COVID-19 within the facility, two residents and two staff.

During today's visit, LPAs conducted a tour of the facility with an emphasis on infection control. The LPA's observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions. The facility has not submitted to the Department the Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC808). Administrator agreed to submit the COVID-19 Mitigation plan to the Department by no later than 5:00PM Tuesday 3/22/22.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code or Regulations.

However, a Technical Assistance (TA) was provided due to the facility staff not being fit tested for N95 masks.

An exit interview, to review this report, was conducted and a copy was provided to administrator Sylvia Busby.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1