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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881036
Report Date: 05/19/2022
Date Signed: 05/19/2022 11:33:34 AM

Document Has Been Signed on 05/19/2022 11:33 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:A HOME 4 WAYNE, INC. 2FACILITY NUMBER:
331881036
ADMINISTRATOR:WATSON, PAMELAFACILITY TYPE:
735
ADDRESS:1591 ATLAS PEAK LN.TELEPHONE:
(951) 219-2467
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 4CENSUS: 0DATE:
05/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Administrator Pamela WatsonTIME COMPLETED:
11:35 AM
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On 05/19/2022 Licensing Program Manager (LPM) J. Harris and Licensing Program Analyst (LPA) V. Mixson arrived at 10:24 am on the above date to conduct the annual inspection. LPA's were greeted and granted entry by Administrator Pamela Watson's, son.

LPA Mixson explained the purpose of the visit and toured the facility with Administrator. Currently there are no residents living in the facility and no cases of COVID-19.

LPM and LPA toured the facility and made observations pertaining to the facility's infection control measures. LPM and LPA observed 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 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 later discussed infection control practices and procedures with Administrator. Although there was a central entry point, no screening protocols were conducted. A Technical Assistance (TA) was provided.

An exit interview was conducted, and a copy of this report, along with the LIC 9102 was provided to Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
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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