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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412261
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:09:59 PM

Document Has Been Signed on 09/21/2022 03:09 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:MICHAEL ANDREW CENTERFACILITY NUMBER:
336412261
ADMINISTRATOR:ROMEO LABASTIDAFACILITY TYPE:
740
ADDRESS:10904 ARIZONA AVETELEPHONE:
(951) 343-9197
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6CENSUS: 6DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Romeo Labastida, AdminstratorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 1:28 PM, LPA was met by
Administrator Romeo Labastida and explained the purpose of the visit. Present in the facility during time of visit were two (2) staff as well as four (4) residents; one (1) at Bible Study and one (1) at program. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed insufficient signage throughout the facility, insufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and no proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, PPE supplies need to be maintained at the facility, cleaning and disinfection provisions are in inadequate quantities, and that staff are not trained in the proper use and disposal of PPE and 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. The facility also needs to maintain a plan to monitor resident(s) and staff 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.

Based on the observations made during today’s visit, ten (10) Technical Assistant and one (1) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview to review this report was conducted and a copy of this report, 809-D and Appeal Rights was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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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Document Has Been Signed on 09/21/2022 03:09 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 09/21/2022 at 02:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MICHAEL ANDREW CENTER
FACILITY NUMBER: 336412261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
80087
Buildings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safty and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Degado's observation and interview, LPA observed a roach on top of the desk in the living room and the wall in the hallway kitchen. The licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Licensee will submit a plan to get rid of the insects and obtain a licensed exterminator. Licensee will submit documentation by POC to LPA Delgado.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
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