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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880905
Report Date: 09/01/2022
Date Signed: 09/01/2022 12:50:38 PM


Document Has Been Signed on 09/01/2022 12:50 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:TEMECULA MEMORY CAREFACILITY NUMBER:
331880905
ADMINISTRATOR:GEDDIE, JAMESFACILITY TYPE:
740
ADDRESS:44320 CAMPANULA WAYTELEPHONE:
(951) 428-4990
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:64CENSUS: 42DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Azizi Baranauskas, Director,
James Geddie, Administrator
Julianne De La Torre, IP Nurse 		TIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA), Chinwe Nwogene made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA met with Administrator, James Geddie, Resident Care Director, Azizi Baranauskas and Julianne De La Torre, IP Nurse who was informed of the purpose of the visit. LPA was informed that facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility inside and out with Azizi Baranauskas and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towels) in all restrooms. LPA did not observe any pools or bodies of water within the premises. No annual fees due.

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be any event of COVID-19 related illnesses. The facility has a designated infection control lead. The facility also cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies. No deficiencies noted at the time of visit.

An exit interview was conducted, and a copy of this report was reviewed and provided to Azizi Baranauskas.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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