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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411389
Report Date: 06/21/2022
Date Signed: 06/21/2022 04:27:20 PM

Document Has Been Signed on 06/21/2022 04:27 PM - 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:CASA MICHANAFACILITY NUMBER:
336411389
ADMINISTRATOR:NANCY MOQUETEFACILITY TYPE:
735
ADDRESS:29161 BRIDALVEIL LANETELEPHONE:
(951) 746-3416
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 5CENSUS: 3DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:42 PM
MET WITH:Administrator- Marcela Hurtado TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA met with administrator Marcela Hurtado, who was informed of the purpose of the visit. At the time of the visit there was 2 staff and 3 residents 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 a single entry point that was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. The facility had a plan in place to monitor residents regularly for any changes in condition. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA observed a sufficient 30-day supply of PPE equipment. The facility also has a plan in place to clean and disinfect the highly touched surfaces. Administrator was able to provide LPA with Mitigation plan LIC 808 that the facility is currently following.

There were no deficiencies noted at the time of the visit. Technical advisory notes were documented on LIC9102TA and LIC9102TV forms. An exit interview was conducted, and a copy of this report along with advisory notes was reviewed and provided to facility administrator, Marcela Hurtado.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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