336412798-1-13-2023-18-AS-JARA-CN2SNM-20230113130147

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336412798
Report Date: 01/13/2023
Date Signed: 01/13/2023 01:02:00 PM

Document Has Been Signed on 01/13/2023 01:02 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:	AFFINITY SENIOR LIVING 1		FACILITY NUMBER:	336412798
ADMINISTRATOR:	ANALISA CAYABYAB		FACILITY TYPE:	740
ADDRESS:	68842 RISUENO ROAD		TELEPHONE:	(760) 322-7905
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	10	CENSUS: 10	DATE:	01/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Administrator, ANALISA CAYABYAB		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit on 1/13/2023 at 11:15 a.m. in order to conduct an annual visit with a focus on infection control. LPA met with Administrator, ANALISA CAYABYAB, who was informed of the purpose of the visit. At the time of the visit there were (4) staff and (10) residents present. LPA proceed to conduct a walk through of the facility's interior and exterior. LPA observed there was a central entry point for facility visits. LPA observed COVID-19 postings at the facility. The facility has a 30-day supply of PPE equipment that is readily accessible for residents and staff. LPA observed the resident bedrooms that would be used as isolation rooms. The resident bathrooms were observed to be clean and have the appropriate hand hygiene supplies such as hand sanitizer, soap, running water and paper towels. The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility and the isolation rooms. The staff have leave in case of contact or testing positive for COVID-19. The staff have been trained on how to properly don and doff the PPE equipment, and there is a plan of care in place to attend to those residents that would be in the isolation rooms. The staff have also been FIT tested for an N95 respiratory and will be due for their annual test. LPA was informed that the facility is no longer taking temperatures for staff and visits. LPA will document a technical advisory note, that administrator was advised to conduct temperature checks on a regular basis for visitors and staff at the beginning of their shift LPA asked for a copy of the resident roster and administrator was unable to locate it during the time of the visit. LPA advised administrator to have this readily available for licensing review. LPA was able to review list of staff names on facility emergency disaster plan. This will be documented on a technical advisory note. The administrator will email a copy of the staff roster to the LPA by today close of business.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

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: AFFINITY SENIOR LIVING 1	FACILITY NUMBER: 336412798
	VISIT DATE: 01/13/2023

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During the time of the visit, LPA observed staff were not wearing their face masks. LPA advised administrator of the current guidance for all staff to wear face masks inside of the facility. Staff put on their face mask immediately after LPA advised them to. This will be documented on a technical advisory note for staff to continue this practice.

LPA observed the facility had a pool in the backyard, and observed the locked gate securing the pool.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where this report was reviewed and provided to Administrator, ANALISA CAYABYAB.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

LIC809 (FAS) - (06/04)

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