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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880999
Report Date: 10/20/2022
Date Signed: 10/20/2022 02:07:48 PM


Document Has Been Signed on 10/20/2022 02:07 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: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: 6DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:Lucia Cornea, House ManagerTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection, with emphasis on infection control. LPA was greeted by Manager Lucia Cornea and explained the purpose of today's visit. There were 6 residents inside the facility during the visit.

LPA toured the facility and made observations pertaining to the facility’s infection control measures. LPA observed proper signage throughout the facility, sufficient hand hygiene supplies, and sufficient cleaning and disinfecting provisions also 30 days supply of Personal Protective Equipment (PPE).

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19. When and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas.

The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illness.

An exit interview was conducted, and a copy of this report was discussed with and provided to Ms. Cornea.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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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