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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336410667
Report Date: 02/07/2022
Date Signed: 02/07/2022 12:10:54 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:DOLORES HOMECAREFACILITY NUMBER:
336410667
ADMINISTRATOR:ANALISA CAYABYABFACILITY TYPE:
740
ADDRESS:30758 BLOOMSBURY LANETELEPHONE:
(760) 202-6609
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:4CENSUS: 4DATE:
02/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Analisa Cayabyab - Administrator/LicenseeTIME COMPLETED:
12:15 PM
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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 Analisa Cayabyab 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 Analisa Cayabyab, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap, but not paper towels. LPA Colvin inquired about the lack of paper towels, and staff were able to restock the bathrooms while LPA Colvin was conducting the inspection. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection instead of a deficiency, as staff were able to restock paper towels. While touring the facility, LPA Colvin observed postings throughout the facility 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 Analisa Cayabyab 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 Administrator Analisa Cayabyab informed LPA Colvin that at this time staff have only been trained on donning/doffing PPE. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Administrator Analisa informed LPA Colvin that she has looked into fit testing for staff, but the sites are all booked.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: DOLORES HOMECARE
FACILITY NUMBER: 336410667
VISIT DATE: 02/07/2022
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LPA Colvin will be providing Administrator with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

LPA Colvin did not observed a sign-in sheet when entering the facility, but the Administrator was able to produce one, which is kept in a drawer due to a resident with a behavior of ripping paper. Additionally, LPA Colvin's temperature was not taken before entering the facility, or being permitted to move about the facility. LPA Colvin will be issuing a Technical Assistance Advisory Note due to staff not screening visitors who enter the facility for COVID-19 symptoms, such as by taking their temperature. The Administrator additionally informed LPA Colvin that the facility staff are informed of the updated visitation guidelines regarding vaccinations and boosters, as well as guests having a negative COVID-19 test, and the facility is keeping record of visitor information to ensure compliance with the State guidelines.

LPA Colvin was shown a copy of the facility's Mitigation Plan during today's inspection, but LPA Colvin was unable to locate one in CCL's files. LPA Colvin requested for the Administrator to fax a copy of the Mitigation Plan to LPA Colvin later today.

An exit interview was conducted with Administrator Analisa Cayabyab and a copy of this report and LIC9102 TA Advisory Notes were provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
LIC809 (FAS) - (06/04)
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