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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881104
Report Date: 04/18/2022
Date Signed: 04/18/2022 01:37:27 PM

Document Has Been Signed on 04/18/2022 01:37 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:GRAYSTONE RESIDENTIAL CAREFACILITY NUMBER:
331881104
ADMINISTRATOR:RANDLE, DEANAFACILITY TYPE:
735
ADDRESS:27630 GRAYSTONE LANETELEPHONE:
(951) 696-7496
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 4CENSUS: 0DATE:
04/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Deana RandleTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by licensee, Deana Randle, who was informed of the purpose of the visit. At the time of visit there was 1 staff and 0 residents present. The facility currently has zero positive or suspected Covid-19 cases.

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 in the facility and advised licensee to have postings on main entrance and throughout the facility. This will be documented on an LIC 9102TA. A single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. Common areas such as dinning rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA was informed of staff training in the proper use of PPE equipment, and observed a sufficient 30-day supply. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces. No deficiencies were given at this time.

An exit interview and a copy of this report was provided to licensee, Deana Randle.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
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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