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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881194
Report Date: 01/06/2023
Date Signed: 01/06/2023 03:37:23 PM

Document Has Been Signed on 01/06/2023 03:37 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:EHIEMERE RESIDENTIAL CARE HOMESFACILITY NUMBER:
331881194
ADMINISTRATOR:EHIEMERE, CHYKEFACILITY TYPE:
735
ADDRESS:14311 QUINCY STREETTELEPHONE:
(951) 992-9065
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 0DATE:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lead Caregiver, Dulce Carrillo.TIME COMPLETED:
03:50 PM
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On January 06, 2023 Licensing Program Analyst (LPA), Venus Mixson arrived at the above facility for an unannounced required annual with emphasis on infection control. LPA Mixson was greeted and granted entry by Lead Caregiver, Dulce Carrillo introduced self and stated the purpose of the visit.

Present in the facility were 0 residents and 1 staff. There are currently no cases of COVID-19 within the facility.

LPA Mixson toured the facility and made observations pertaining to the facility's infection control measures. LPA Mixson 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 Mixson later discussed infection control practices and procedures with Lead Caregiver.

An exit interview was conducted, and a copy of this report was provided to Lead Caregiver.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2023
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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