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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412338
Report Date: 06/22/2022
Date Signed: 06/22/2022 11:56:43 AM

Document Has Been Signed on 06/22/2022 11:56 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:CHARLINE'S ADULT RESIDENTIAL FACILITY IIFACILITY NUMBER:
336412338
ADMINISTRATOR:WILLS, CHARLINEFACILITY TYPE:
735
ADDRESS:24956 SPRINGBROOK WAYTELEPHONE:
(951) 246-7339
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 4CENSUS: DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Licensee- Charline WillsTIME COMPLETED:
12:00 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 licensee Charlene Wills, who was informed of the purpose of the visit. At the time of visit there was 2 staff and 4 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 Covid-19 postings at the facility and a single entry point. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in facility restrooms. Common areas such as dining rooms and living 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 designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces.

There were no deficiencies noted at the time of the visit. An exit interview was conducted, and a copy of this report was reviewed and provided to facility licensee, Charlene Wills.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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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