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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411977
Report Date: 08/23/2022
Date Signed: 08/23/2022 10:24:49 AM

Document Has Been Signed on 08/23/2022 10:24 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:FOUR SEASONS ELDERLY CARE HOME, INC.FACILITY NUMBER:
336411977
ADMINISTRATOR:VALDOVINO, TERESITAFACILITY TYPE:
740
ADDRESS:81-399 AVENIDA COYOTETELEPHONE:
(760) 702-3878
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY: 6CENSUS: 5DATE:
08/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Teresita Valdovino, Administrator TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct an annual inspection with emphasis on infection control. LPA met with Administrator Teresita Valdovino and explained the purpose of today’s visit.

During the inspection, LPA observed appropriate COVID-19 postings in the facility which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA observed facility staff wearing appropriate face coverings. As documented in the facility's Mitigation Plan Report, the facility has a designated infection control lead person/infection preventionist who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring staff are trained in the facility's infection control procedures, and ensuring infection control measures are implemented. Also detailed in the Report is a plan which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, properly caring for residents and staff with COVID-19 positive results and/or exposures as well as a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician, emergency personnel, and responsible party in the event the resident presents with any COVID-19 symptoms.

No deficiencies were observed during today's visit. An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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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