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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880943
Report Date: 07/22/2022
Date Signed: 07/22/2022 02:39:49 PM

Document Has Been Signed on 07/22/2022 02:39 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:ELEVATION HOMEFACILITY NUMBER:
331880943
ADMINISTRATOR:OLOSO, IFEOLUWA VICTORIAFACILITY TYPE:
735
ADDRESS:4390 WILLOWGLEN WAYTELEPHONE:
(559) 385-0423
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 4CENSUS: 3DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ifeoluwa Oloso - Licensee/AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Licensee/Administrator Ifeoluwa Oloso 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:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Licensee/Administrator Ifeoluwa Oloso, who LPA Colvin found to be successfully incorporating the several 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. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in the in the garage and easily accessible to staff. LPA Colvin observed the facility to have an adequate supply of PPE. LPA Colvin went over the various recommended training for facility staff with Licensee/Administrator Ifeoluwa Oloso in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Licensee/Administrator Ifeoluwa Oloso informed LPA Colvin that at this time staff have only been trained on donning/doffing PPE. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin 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. LPA Colvin will be providing Licensee/Administrator Ifeoluwa Oloso with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks. LPA Colvin additionally advised Licensee/Administrator on N95 fit testing being required by CAL-OSHA, as LPA Colvin observed facility was given TA for this in 2021 as well.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ELEVATION HOME
FACILITY NUMBER: 331880943
VISIT DATE: 07/22/2022
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LPA Colvin inquired about if the facility is screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Licensee/Administrator Ifeoluwa Oloso stated that residents are not being screened daily at this time. LPA Colvin will be issuing a TA Advisory Note as it is recommended for residents to continue to be screened daily at this time. LPA Colvin confirmed that staff and visitors are screened prior to entry into the facility, as LPA Colvin's temperature was taken prior to being let inside.

Other: When walking up to the facility, LPA Colvin observed the facility's garbage and recycling containers to be consuming a substantial (at least half) portion of the walkway on the left side of the house, near the garage. Additionally, as LPA Colvin walked up the pathway towards the front door of the facility, LPA Colvin observed what appeared to be the broken base of a plastic basketball stand/hoop in the middle of the walkway. These items present as potential trip hazards and barriers for safe and prompt exit in case of an emergency. Deficiency cited.

An exit interview was conducted with Licensee/Administrator Ifeoluwa Oloso and a copy of this report and LIC9102 TA Advisory Notes was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2022 02:39 PM - It Cannot Be Edited


Created By: Crystal Colvin On 07/22/2022 at 02:22 PM
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: ELEVATION HOME
FACILITY NUMBER: 331880943

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Buildings and Grounds: (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatio, the licensee did not comply with the section cited above in 2 out of 2 outdoor walkways, which poses a potential safety risk to persons in care. LPA Colvin observed both outdoor walkways to have large items partially obstructing the path. LPA Colvin observed three garbage/recycling bins covering half of the side walkway by the garage, and a broken peice of sports equipment (basketball hoop/stand) blocking part of the walkway leading up to the front door of the facility.
POC Due Date: 08/05/2022
Plan of Correction
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Licensee agrees to remove the broken sports equipment from the front walkway and dispose of it promptly and appropriately. Licensee additionally agrees to relocate the garbage/recycling bins to ensure that they do not present as a potential obsticle for residents/staff if they were to need to exit the facility from that side in a hurry. Licensee to provide LPA Colvin with photographs of cleared outdoor passageways by the Plan of Correction date of 8/5/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022


LIC809 (FAS) - (06/04)
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