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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880932
Report Date: 08/27/2021
Date Signed: 08/27/2021 11:10:42 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/27/2021 11:10 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:DAWSON HOMES INC. ON JEANNIE ANN CIRCLEFACILITY NUMBER:
331880932
ADMINISTRATOR:HAWTHORNE, ADINAFACILITY TYPE:
735
ADDRESS:7889 JEANNIE ANN CR.TELEPHONE:
(951) 898-7692
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY: 4CENSUS: 4DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Dania Jeffries, CaregiverTIME COMPLETED:
12:00 PM
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This is a copy of an annual visit report initially conducted and delivered to this facility on 08/25/2021 inadvertently keyed to the wrong facility number 361880929.

Licensing Program Analyst (LPA) Amy Goldenberg made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. There are two clients and one staff present at the time of this visit. LPA observed that face masks are being worn. LPA is informed that there are no COVID positive individuals in the home. Upon entry LPA was directed to a table with hand sanitizer, thermometer and visitation log and was asked to sign in.

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and a supply of personal protective equipment (PPE). The facility continues to monitor client regularly for any changes in condition, and notify the client's physician and emergency personnel in the event the client presents any COVID-19 symptoms.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. LPA
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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