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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403710
Report Date: 08/16/2022
Date Signed: 08/16/2022 09:50:47 AM


Document Has Been Signed on 08/16/2022 09:50 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:MURRIETA HOME CAREFACILITY NUMBER:
336403710
ADMINISTRATOR:MARIA ARACELI UNDANFACILITY TYPE:
740
ADDRESS:41035 CHACO CANYON ROADTELEPHONE:
(951) 600-1294
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:6CENSUS: 4DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Arvin Valenciano - CaregiverTIME COMPLETED:
10:00 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 caregiver Arvin Valenciano and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Caregiver Valenciano informed LPA Colvin that this morning a resident tested positive for COVID-19. Therfore, LPA Colvin conducted the review of Infection Control best practices via telephone with Licensee Maria Araceli Undan, and briefly inspected the facility. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Licensee Maria Araceli Undan, 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. LPA Colvin viewed the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which LPA Colvin determined to be sufficient for a 30-day supply. These PPE supplies are accessible to staff and there is a designated PPE donning/doffing station outside of the isolation room. LPA Colvin went over the various recommended training for facility staff with Licensee Maria Araceli Undan 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.

Licensee Maria Araceli Undan informed LPA Colvin that staff have not yet been fit tested for N95 masks. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. Licensee Maria Araceli Undan 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. LPA Colvin additionally confirmed the presence of a sign-in log for visitors, where their temperature is recorded as well as answers to screening questions. An exit interview was conducted with Licensee Maria Araceli Undan and a copy of this report and Technical Advisory Note was provided. Report signed by Licensee Maria Araceli Undan as Licensee not physically present during inspection.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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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