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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423521
Report Date: 05/20/2021
Date Signed: 05/20/2021 03:36:16 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:ABBEY ELDER CARE, INC.FACILITY NUMBER:
336423521
ADMINISTRATOR:SUNDEEP RANDHAWAFACILITY TYPE:
740
ADDRESS:3412 WEXFORD CIRCLETELEPHONE:
(951) 858-8641
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:6CENSUS: 5DATE:
05/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Leonor MurilloTIME COMPLETED:
04:06 PM
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Licensing Program Analyst (LPA) Jennifer Semin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility via telephone. LPA met with House Manager Leonor Murillo 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:
LPA went over COVID-19 best practices for infection control and prevention with Ms. Murillo who is successfully incorporating the numerous aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for local fire department has been updated.
LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located on the kitchen counter for convenience. LPA observed a space in a kitchen cabinet dedicated to storing all PPE items such as gloves, face shields, gowns, surgical masks and N95 masks. Disinfectant and hand sanitizer supply is stored in the laundry room and inaccessible to residents. LPA observed a minimal supply of PPE readily available for use. LPA and Ms. Murillo discussed creating a box, or similar, to have a supply of PPE ready that would be dedicated for isolation room, along with a trash can to put outside of an isolation room.
LPA inquired as to if staff have been fit tested for N95 masks, and Ms. Murillo stated the staff have not been fit tested. LPA will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA 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. Additionally, residents have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA provided Ms. Murillo with the Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.
An exit interview was conducted with Ms. Murillo and a copy of this report, a copy of PIN 21-10-ASC and LIC9102 TA Advisory Note was provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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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