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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881027
Report Date: 02/16/2022
Date Signed: 02/16/2022 01:17:41 PM

Document Has Been Signed on 02/16/2022 01:17 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:SUPERIOR CARE GUEST HOMEFACILITY NUMBER:
331881027
ADMINISTRATOR:NGUYEN, KELVINFACILITY TYPE:
740
ADDRESS:994 PAINTBRUSH TRAILTELEPHONE:
(951) 357-2049
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 6CENSUS: DATE:
02/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Caregiver, Melchor HitallaTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Cuevas made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by caregiver, Melchor, who was informed of the purpose of the visit. At the time of visit there was 1 staff and 4 residents present. The facility currently has zero positive or suspected Covid-19 cases. LPA did not observe any pools or bodies of water within the premises. LPA was informed that no weapons or ammunition is maintained at the home. No annual fees due.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer) in all restrooms (2 restrooms.)

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility also has a designated infection control lead and cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies. During walk through LPA identified administrator certificate to be expired for Kelvin H. Nguyen expiration date of 12/1/21, per licensee the training for re-certification and required renewal was submitted back in November 2021; however, a week ago they received notification that due to an error, they will need to resubmit within 30 days, for renewal to be processed. LPA requested for training certificates and re-certification notice to be sent to him for review by the end of the week. Deficiency will be cited.

An exit interview was conducted, and a copy of this report was provided to Melchor.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
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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Document Has Been Signed on 02/16/2022 01:17 PM - It Cannot Be Edited


Created By: David Cuevas On 02/16/2022 at 12:59 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: SUPERIOR CARE GUEST HOME
FACILITY NUMBER: 331881027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87406(h)


This requirement is not met as evidenced by:During a walk through of facility LPA identified Administrator Certificate to be expired on 12/1/21
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2022
Plan of Correction
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Licensee will submit training certifcates and renewal documents by the end of the week, 2/18/22 showing the required training was completed and that submission re-certification sent in for review.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:David Cuevas
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022


LIC809 (FAS) - (06/04)
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