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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412373
Report Date: 08/02/2022
Date Signed: 08/02/2022 03:33:10 PM

Document Has Been Signed on 08/02/2022 03:33 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:JOHN, TRACI, & COFACILITY NUMBER:
336412373
ADMINISTRATOR:SCHWAB, TRACIFACILITY TYPE:
735
ADDRESS:3680 ANCHORAGE ST.TELEPHONE:
(951) 392-2213
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 5CENSUS: 4DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Michelle Camarillo - CaregiverTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with caregiver Michelle Camarillo and advised her of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with caregiver Michelle Camarillo, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Infection Control Plan. Residents have hand sanitizer available to them LPA Colvin was unable to inspect the bathrooms during today's visit, as both bathrooms were being used by residents taking a shower, as they had just returned from Day Program. LPA Colvin did observed that the kitchen sink was stocked with hand soap and paper towels. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns) which LPA Colvin observed to be sufficient for a 30-day supply and is accessible to staff. LPA Colvin went over the various recommended training for facility staff with caregiver Michelle Camarillo 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 PPE.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and caregiver Michelle Camarillo confirmed that they have conducted fit testing for all staff. LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. caregiver Michelle Camarillo confirmed that staff are continuing to monitor residents’ symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility. LPA Colvin observed a check-in station by the front of the facility with a thermometer, sign-in log, hand sanitizer, and extra surgical masks for visitors who may have come without one. An exit interview was conducted with caregiver Michelle Camarillo and a copy of this report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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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