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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403573
Report Date: 09/06/2022
Date Signed: 09/06/2022 11:23:12 AM


Document Has Been Signed on 09/06/2022 11:23 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:VILLAGE, THEFACILITY NUMBER:
336403573
ADMINISTRATOR:ROB TAKAMIFACILITY TYPE:
741
ADDRESS:2200 WEST ACACIATELEPHONE:
(951) 766-5116
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY:452CENSUS: 89DATE:
09/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jennifer Haas - AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Administrator Jennifer Haas 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 Administrator Jennifer Haas, and reviewed the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels, and hand washing guides are posted. Upon entering the facility, LPA Colvin observed postings for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns) which LPA Colvin observed to be sufficient for a 30-day supply. LPA Colvin went over the various recommended training for facility staff with Administrator Jennifer Haas 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.

Administrator Jennifer Haas confirmed that all staff have been fit tested, and that they will be re-fit tested annually. LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Administrator Jennifer Haas confirmed that staff are continuing to monitor residents’ symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility, which LPA Colvin confirmed through being screened upon entry as well. LPAs Colvin additionally observed a sign-in log for visitors, where their temperature is recorded as well as answers to screening questions. LPA Colvin confirmed that facility is following recommendations regarding testing newly hired staff and newly admitted residents prior to entrance to the facility. Facility staff are fully vaccinated, so no weekly surveillance testing is required.
An exit interview was conducted with Administrator Jennifer Haas and a copy of this report was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
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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