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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880960
Report Date: 08/10/2022
Date Signed: 08/10/2022 04:23:04 PM

Document Has Been Signed on 08/10/2022 04:23 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:SIERRA RIDGE HOMEFACILITY NUMBER:
331880960
ADMINISTRATOR:MARCAIDA, NATALIEFACILITY TYPE:
735
ADDRESS:30167 SIERRA RIDGE WAYTELEPHONE:
(951) 926-9977
CITY:MENIFEESTATE: CAZIP CODE:
92585
CAPACITY: 4CENSUS: 3DATE:
08/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Lead Caregiver Marivic AbatTIME COMPLETED:
04:30 PM
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On 08/10/2022, Licensing Program Analyst (LPA), Venus Mixson arrived at the above facility for an unannounced annual with emphasis on infection control. LPA Mixson was greeted and granted entry by Staff-Lead, Marivic Abat. LPA Mixson met with Staff-Lead introduced self and stated the purpose of the visit.

Present in the facility were 3 residents and 2 caregivers. There are currently no cases of COVID-19 within the facility.

LPA Mixson toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions and the proper use of face coverings. All Residents bathrooms had liquid soap and paper towels.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities.

LPA Mixson later discussed infection control practices and procedures with Staff-Lead.

An exit interview was conducted, and a copy of this report along with the LIC 811 was provided to Staff-Lead.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2022
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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