336402994-5-24-2021-18-AS-CCON-C3BSLY-20210524135907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336402994
Report Date: 05/24/2021
Date Signed: 05/24/2021 01:59:19 PM

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:	LIFESTYLE HOME CARE		FACILITY NUMBER:	336402994
ADMINISTRATOR:	MARY MATEAS		FACILITY TYPE:	740
ADDRESS:	5377 CAROL WAY		TELEPHONE:	(951) 684-5833
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	6	CENSUS: 3	DATE:	05/24/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	John Grozav - Caregiver		TIME COMPLETED:	02:00 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) Crystal Colvin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility via phone call. LPA Colvin met with caregiver John Grozav 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 Colvin went over COVID-19 best practices for infection control and prevention with caregiver John Grozav, who LPA Colvin found to be successfully incorporating the numerous aspects of the facility's approved Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap. LPA Colvin observed the resident bathroom to not have any paper towels, but instead there were several cloth towels hanging up in the bathroom. Caregiver John informed LPA Colvin that the facility does not stock the restrooms with paper towels due to residents clogging the toilet with them. LPA Colvin is issuing the facility a Technical Assistance (TA) Advisory Note for the lack of paper towels and use of cloth towels. LPA Colvin is not citing a deficiency due to the Licensee having supplied another means for residents to dry their hands. LPA Colvin still recommends for the towels to not be kept in the bathroom and for residents to either have their own cloth towel that they bring in with them, or for the towels to be one time use before being washed again to ensure no cross-contamination between residents. During LPA Colvin's inspection, facility staff got out paper towels and added them to the restrooms. LPA Colvin went over some additional possible options for the facility to help prevent residents from flushing paper towels, such as keeping them directly outside of the restroom. LPA Colvin additionally observed hand washing guide posted in the bathroom for residents' use. LPA Colvin observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, and social distancing.. LPA Colvin requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was stored near the front door where staff would screen visitors. LPA Colvin observed the facility to have a 30-day supply of gloves, masks, and sanitizer, but the facility did not have any isolation gowns.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

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: LIFESTYLE HOME CARE	FACILITY NUMBER: 336402994
	VISIT DATE: 05/24/2021

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LPA Colvin is issuing a Technical Assistance (TA) Advisory Note during today's inspection for the facility not having a 30-day supply of isolation gowns. LPA Colvin is not issuing a deficiency due to the facility having a 30-day supply of all other PPE, and the fact that isolation gowns are only needed when there is a COVID-19 positive or a resident is under observation pending test results.

LPA Colvin went over the various recommended training for facility staff with caregiver John Grozav in relation to COVID-19, and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. LPA Colvin inquired as to if staff have been fit-tested for N95 masks, and caregiver John informed LPA Colvin that staff have been fit tested for N95 masks. LPA Colvin observed residents to not be wearing masks during LPA Colvin's inspection at the facility, but all residents were in their private bedrooms with the doors closed, so there was no need for them to be wearing a mask. LPA Colvin additionally went over the facility's cleaning procedure with caregiver John Grozav, which are in line with Community Care Licensing and Department of Public Health recommendations.

An exit interview was conducted with caregiver ohn Grozav and a copy of this report and LIC9102 TA Advisory Notes was provided.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC809 (FAS) - (06/04)

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