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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880902
Report Date: 05/25/2021
Date Signed: 05/25/2021 02:44:50 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/25/2021 02:44 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:BUENA VISTA ASSISTED LIVINGFACILITY NUMBER:
331880902
ADMINISTRATOR:NEWCOMB, DOLLYFACILITY TYPE:
740
ADDRESS:1393 S. BUENA VISTA ST.TELEPHONE:
(951) 658-5160
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 49CENSUS: 38DATE:
05/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Dolly NewcombTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Jennifer Semin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility via telephone. LPA met with Administrator Dolly Newcomb 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:
LPA went over COVID-19 best practices for infection control and prevention with Ms. Newcomb who is successfully incorporating the numerous 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. LPA observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for local fire department has been updated.
LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in a common bathroom cabinet, for convenience. LPA observed a storage space dedicated to storing all PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer supply is stored inaccessible to residents. LPA and Ms. Newcomb discussed creating a box, or similar, to have a supply of PPE ready that would be dedicated for isolation room, along with a trash can to put outside of an isolation room.
LPA inquired as to if staff have been fit tested for N95 masks, and Ms. Newcomb stated the staff have not been fit tested. LPA will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, residents have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA will email Ms. Newcomb with the Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.
An exit interview was conducted with Ms. Newcomb and a copy of this report, a copy of PIN 21-10-ASC and LIC9102 TA Advisory Note will be emailed.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2021
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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