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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408502
Report Date: 05/27/2021
Date Signed: 06/14/2021 11:02:32 AM

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:CASA MIAFACILITY NUMBER:
336408502
ADMINISTRATOR:LILIBETH SAMSONFACILITY TYPE:
740
ADDRESS:10650 54TH STREETTELEPHONE:
(951) 685-9000
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY:20CENSUS: 17DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Lilibeth Sampson, AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPA) Amy Goldenberg made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived and observed a hand sanitation and sign in station. The facility is practicing symptom monitoring of visitors and daily monitoring for residents. LPA's temperature was measured during this visit. LPA learned there are seventeen (17) residents residing in the home at this time. There are no cases of COVID-19 in the facility.

The facility has an approved mitigation plan in place which follows Community Care Licensing guidelines. During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions. Adequate personal protective equipment is on hand. Staff are wearing masks and residents are encouraged to participate in hand washing and wearing masks. LPA does not observe any issues that pose immediate harm to the residents of the home.

Based on the observations made during today’s visit, there are no deficiencies being cited per Title 22, Division 6, of the California Code or Regulations. LPA reviewed this report and a copy was provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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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