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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880894
Report Date: 05/19/2022
Date Signed: 05/19/2022 10:10:29 AM

Document Has Been Signed on 05/19/2022 10:10 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:PLEASANT WAYS ADULT RESIDENTIALFACILITY NUMBER:
331880894
ADMINISTRATOR:WALKER, KEITHFACILITY TYPE:
735
ADDRESS:761 AMOR DR.TELEPHONE:
(951) 312-1751
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 4CENSUS: 2DATE:
05/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:BRAIN WALKER MANAGERTIME COMPLETED:
10:15 AM
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On 05/19/2022, Licensing Program Manager (LPM), J. Harris and Licensing Program Analyst (LPA), V. Mixson arrived at 8:52 am on the above date to conduct the annual inspection. LPA's were greeted and granted entry by Brian Walker Manager. Manager conducted proper screening protocols upon entry.

Present in the facility were 0 clients and 1 caregiver. There are currently no cases of COVID-19 within the facility.

LPM and LPA toured the facility and made observations pertaining to the facility's infection control measures. LPM and LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and the proper use of face coverings. No deficiencies were observed.

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 Manager.

An exit interview was conducted, and a copy of this report, along with the LIC 811 was provided to Manager.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
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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