331881042-2-28-2022-18-AS-MBRN-CC3R8Q-20220228114818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881042
Report Date: 02/28/2022
Date Signed: 02/28/2022 11:48:31 AM

Document Has Been Signed on 02/28/2022 11:48 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:	CITY HOME SENIOR LIVING		FACILITY NUMBER:	331881042
ADMINISTRATOR:	NGINA SMITH		FACILITY TYPE:	740
ADDRESS:	1672 GOLDEN WAY		TELEPHONE:	(714) 878-4443
CITY:	BEAUMONT	STATE: CA	ZIP CODE:	92223
CAPACITY:	6	CENSUS: 1	DATE:	02/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Ngina Smith		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Melody Brown arrived at the facility 02/28/2022 at 09:50 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrator Ngina Smith and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed: Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator Ngina Smith and Administrator Smith reported that Mitigation Plan was submitted 10/01/2021. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility's and observed that resident bathrooms have paper towels and hand soap. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, and face shields/goggles and isolation gowns. LPA Brown went over the various recommended training for facility staff with Administrator Smith in relation to COVID-19 and Administrator Smith reported that all staff were trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Smith informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive resident, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, all residents and staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown informed Administrator Smith of the Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks. * Continuation in LIC809C *

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CITY HOME SENIOR LIVING	FACILITY NUMBER: 331881042
	VISIT DATE: 02/28/2022

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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. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their residents for COVID-19, when and how to isolate/quarantine resident, 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 their residents regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

An exit interview was conducted with Administrator Ngina Smith and a copy of this report (LIC809) and LIC9102 AN Technical Assistance Advisory Note were provided.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

LIC809 (FAS) - (06/04)

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