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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411100
Report Date: 05/26/2022
Date Signed: 05/26/2022 10:08:40 AM

Document Has Been Signed on 05/26/2022 10:08 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:WARWICK RESIDENTIAL CAREFACILITY NUMBER:
336411100
ADMINISTRATOR:DAMON M. DUCLAYANFACILITY TYPE:
735
ADDRESS:2010 WARWICK ST.TELEPHONE:
(951) 294-0356
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 6CENSUS: 4DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Shirley Jardin, CaregiverTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Caregiver Shirley Jardin and explained the purpose of the visit. The Administrator was available via telephone due to being at an appointment. At the time of visit there were 2 staff and 4 client's present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility including the proper hand washing steps. The facility has an adequate supply of Personal Protective Equipment (PPE) and EPA approved cleaners.

Upon entry LPA observed that the facility did not have their visitation policy posted at the entrance. The facility has implemented a covid screening that includes a questionnaire and taking the temperature of any visitors, however there is not a sign sheet.

The client's temperatures are also taken once a day at the facility, but the temperatures are not being documented. Additionally, the facility staff have not been FIT tested. LPA provided PIN 21-10-ASC, to connect the facility staff to the available FIT testing resources. LPA provided technical assistance pertaining to covid related protocol to the Caregiver as well as Administrator Suzette Manalansan.

An exit interview was conducted and a copy of this report was provided to caregiver Shirley Jardin.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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