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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880999
Report Date: 10/07/2021
Date Signed: 10/07/2021 01:42:54 PM

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:MD PREMIER CARE HOMEFACILITY NUMBER:
331880999
ADMINISTRATOR:DOLHA, MIRCEAFACILITY TYPE:
740
ADDRESS:45911 PASEO CORONADOTELEPHONE:
(949) 335-2364
CITY:INDIAN WELLSSTATE: CAZIP CODE:
92210
CAPACITY:6CENSUS: 4DATE:
10/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Asucena Delvaal, CaregiverTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control.

LPA Gardner met with Caregiver Asucena Delvaal. Present in the home during time of visit were 4 clients. There are currently no cases of COVID-19 within the facility. While touring the facility, Licensee/Administrator Mircea Dolha arrived in the facility.

During today's visit, LPA Gardner toured the facility and made observations pertaining to the facility's infection control measures. LPA Gardner observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. 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, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control.

During the inspection LPA Gardner discussed infection control practices and procedures with Mr. Dolha.

An exit interview was conducted and a copy of this report, was reviewed with and provided to Mr. Dolha.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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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