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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880889
Report Date: 06/22/2022
Date Signed: 06/22/2022 12:12:17 PM

Document Has Been Signed on 06/22/2022 12:12 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:ELDERLY BETTER HOMEFACILITY NUMBER:
331880889
ADMINISTRATOR:ALSAYEH, HALAFACILITY TYPE:
740
ADDRESS:20461 MYRON STTELEPHONE:
(951) 349-3440
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 2CENSUS: 0DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Ramsey Alsayeh, LicenseeTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 10:55 AM, LPA was met by Licensee Ramsey Alsayeh and explained the purpose of the visit. Present in the facility during time of visit were one (1) staff as well as zero (0) residents and two (2) minor children of the Licensee. There are currently no cases of COVID-19 within the facility. Licensing Program Analyst Yolanda Delgado attempted to complete the Annual visit with emphasis on Infection Control on May 27, 2022. No answer at the door when door bell rang, no answer with a knock at the door. Windows are shut closed, debris and trash in the front enclosed yard.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed insufficient signage throughout the facility, insufficient hand hygiene supplies, insufficient cleaning and disinfecting provisions, and no 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, PPE supplies need to be maintained at the facility, cleaning and disinfection provisions are in inadequate quantities, and staff are not 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 needs to maintain a plan to monitor resident(s) 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, two (2) 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: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
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 06/22/2022 12:12 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/22/2022 at 11:46 AM
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: ELDERLY BETTER HOME
FACILITY NUMBER: 331880889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87311
Telephones
All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation and interview, the Licensee confirmed there is no active landline phone at the facility, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/06/2022
Plan of Correction
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Licensee will obtain a landline phone and send self-certification of landline service and telephone number to CCLD by 5pm on POC.
Type B
Section Cited
CCR
87468.2(a)
Additional Personal Rights of Residents in Privately Operated Facilities: a) In addition to the rights listed in Section 87468.1 Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and records review, the licensee did not ensure COVID-19 Infection Control measures: COVID-19 screening protocols and practices for all staff, residents and visitors, insufficient signage of Infection Control, insufficient PPE supplies. The Licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/06/2022
Plan of Correction
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Licensee will send corrections to CCLD by 5pm on POC.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
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