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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336410692
Report Date: 01/03/2022
Date Signed: 02/07/2022 08:01:43 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:EASTVALE MEADOWSFACILITY NUMBER:
336410692
ADMINISTRATOR:SIMM SANASINHFACILITY TYPE:
740
ADDRESS:6885 CEDAR CREEK ROADTELEPHONE:
(951) 520-1074
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 5DATE:
01/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Amelia RodriguezTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Amy Goldenberg made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA is informed that there are no COVID positive individuals in the home. The facility has an approved mitigation plan on file with this agency. Precautionary Covid-19 postings are present at the front door. LPA was granted entry. There is hand sanitizer at the entry and a restroom available for hand washing, however, LPA was not asked to do so. LPA was not screened for symptoms upon entry. All staff are observed to be wearing masks. LPA is advised that there are two (2) caregivers, five (5) residents present during this visit.

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and has a limited supply of Personal Protective Equipment (PPE). LPA discussed the availability of additional PPE supplies to the facility at the time of this visit and advised the facility representatives to contact our office in the event additional supplies are necessary. The facility continues to monitor client regularly for any changes in condition, and notify the client's physician and emergency personnel in the event the client presents any COVID-19 symptoms. Isolation procedures are in place. Hand sanitizer is available for resident and staff use at various points through out the facility. Each restroom available for hand washing has hand washing posting. Staff are courteous and engaged in resident care during LPA inspection. Staff were provided with technical assistance pertaining to COVID-19 mitigation during this visit. Based on observations made during today’s inspection, there are no deficiencies being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with 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: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
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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