336412255-1-4-2022-18-AS-MBRN-CAD2LW-20220104163013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336412255
Report Date: 01/04/2022
Date Signed: 01/04/2022 04:30:22 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:	LIFESTYLE HOME CARE II		FACILITY NUMBER:	336412255
ADMINISTRATOR:	MARY MATEAS		FACILITY TYPE:	740
ADDRESS:	5417 SKYLOFT DRIVE		TELEPHONE:	(951) 360-1622
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	6	CENSUS: 5	DATE:	01/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Mary Mateas		TIME COMPLETED:	04:35 PM

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Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to conduct an annual inspection, with emphasis on infection control. LPA Brown was greeted and granted entrance by Administrator Mary Mateas and LPA Brown explained the purpose of today's visit. Administrator Mateas accompanied LPA Brown on a tour of the inside and outside of the facility.

During today’s visit, LPA Brown made observation pertaining to the facility’s current infection control measures. LPA Brown observed a screening area, proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

LPA Brown went over the various recommended training for facility staff with Administrator Mateas 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 of PPE. LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Mateas informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks.

***** continuation on LIC809C *****

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

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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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: LIFESTYLE HOME CARE II	FACILITY NUMBER: 336412255
	VISIT DATE: 01/04/2022

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LPA Brown 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. Additionally, all residents and staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. Administrator Mateas reported that they have a copy of the Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

An exit interview was conducted with Administrator Mateas and a copy of this report (LIC 809) and LIC9102 TA Advisory Notes were provided.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

LIC809 (FAS) - (06/04)

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