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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403573
Report Date: 08/26/2021
Date Signed: 08/26/2021 02:10:34 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:VILLAGE, THEFACILITY NUMBER:
336403573
ADMINISTRATOR:ROB TAKAMIFACILITY TYPE:
741
ADDRESS:2200 WEST ACACIATELEPHONE:
(951) 766-5116
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY:452CENSUS: 289DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Administrator's Michelle Flores and Jennifer HaasTIME COMPLETED:
12:23 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Administrator Jennifer Haas and explained the purpose of the visit. LPA met with both Administrator's Michelle Flores and Jennifer Haas. Note that the census for Assisted Living is 44. 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 posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer). Staff were also observed wearing appropriate face coverings (Face shields and surgical masks, or face shields and N95 masks).

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility also has a designated infection control lead and cleans and disinfects the highly touched surfaces during each shift, and as needed. The facility submitted their mitigation plan and was observed to following the plan as indicated.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and a copy of this report was provided to Administrator's Michelle Flores and Michelle Haas.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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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