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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880959
Report Date: 09/30/2021
Date Signed: 09/30/2021 10:57:31 AM

Document Has Been Signed on 09/30/2021 10:57 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:MOUNT MENIFEE HOMEFACILITY NUMBER:
331880959
ADMINISTRATOR:MARCAIDA, NATALIEFACILITY TYPE:
735
ADDRESS:30138 MOUNT MENIFEE STTELEPHONE:
(626) 675-7256
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 4CENSUS: 0DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Omar Talla, NatalieTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Deborah Mullen conducted a annual inspection on this date. LPA met with Omar Talla, Licensee. Currently the home does not have any residents residing in the home. The home is licensed for four ambulatory developmentally disabled adults, ages 18-59 years of age.

LPA inspected the facility and made observations pertaining to the facility's infection control measures. LPA reviewed current policies and procedures with the Licensee and Department expectations prior to residents being placed in the home. LPA reviewed the expectation that the facility have sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and the proper use of face coverings. The facility has a designated infection control lead person who will track all COVID-19 cases and/or suspected cases, ensure PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and staff are trained in the proper use and disposal of PPE supplies and overall infection control. The facility has submitted a Mitigation Plan which details their plan relating to infection control.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted and a copy of this report was reviewed with and provided to Mr. Talla.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Deborah Mullen
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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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