336423364-1-6-2022-18-AS-CCON-CAEUW3-20220106145605

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336423364
Report Date: 01/06/2022
Date Signed: 01/06/2022 02:56:24 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:	ISLAND'S BEST HOME CARE LLC		FACILITY NUMBER:	336423364
ADMINISTRATOR:	ARCITA CAYABYAB		FACILITY TYPE:	740
ADDRESS:	30875 AVENIDA JUAREZ		TELEPHONE:	(760) 832-8975
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	6	CENSUS: 6	DATE:	01/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Arcita Cayabyab - Administrator		TIME COMPLETED:	03:00 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) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Administrator Arcita Cayabyab and advised 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 Administrator Arcita Cayabyab, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Mitigation Plan. 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. LPA Colvin went over the various recommended training for facility staff with Administrator Arcita Cayabyab 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 inspected the various resident bathrooms at the facility, and observed two of the four bathrooms to be missing hand soap and/or paper towels. Staff was able to stock the bathrooms during LPA Colvin's inspection. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for the lack of soap and paper towels present in two of the resident bathrooms. LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Arcita Cayabyab informed LPA Colvin that at this time staff have only been trained on donning/doffing PPE. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin 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. LPA Colvin will be providing Administrator with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for fit testing.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

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: ISLAND'S BEST HOME CARE LLC	FACILITY NUMBER: 336423364
	VISIT DATE: 01/06/2022

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LPA Colvin inquired about if the facility is screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Administrator Arcita Cayabyab confirmed that residents and staff are being screened daily for COVID-19 symptoms. LPA Colvin observed a sign-in sheet at the front door of the facility, which LPA Colvin used to sign-in at the beginning of today's inspection.

Other Items: Prior to LPA Colvin's entry to the facility, LPA Colvin observed a several large objects on the pathway between the emergency exit from the backyard and the driveway. Objects included: large cardboard box, large piece of foam, part of wooden furniture, walker, and garbage and recycling bins. All walkways are to be kept free of debris or obstruction in case they need to be used by a resident, staff, or emergency personnel. Deficiency cited.

An exit interview was conducted with Administrator Arcita Cayabyab and a copy of this report, LIC809D, and LIC9102 TA Advisory Notes were provided.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: ISLAND'S BEST HOME CARE LLC	FACILITY NUMBER: 336423364
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in at least one passageway (walkway for emergency exit from backyard to driveway) which poses a potential safety risk to persons in care.
	POC Due Date: 01/13/2022
	Plan of Correction
1 2 3 4	Licensee agrees to have the clutter (large cardboard box, large piece of foam, piece of wooden furniture, walker) and trash bins moved from the walkway that connects the backyard/emergency exit to the driveway, by the Plan of Correction date of 1/13/22. Licensee to provide LPA Colvin with photographic proof of correction.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

LIC809 (FAS) - (06/04)

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