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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423630
Report Date: 12/06/2022
Date Signed: 12/06/2022 03:50:30 PM

Document Has Been Signed on 12/06/2022 03:50 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:MEMBERS CLUB RESIDENTIAL CAREFACILITY NUMBER:
336423630
ADMINISTRATOR:APODACA, CHRISTOPHER JFACILITY TYPE:
735
ADDRESS:38516 MEMBERS CLUB DRIVETELEPHONE:
(951) 319-6719
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 4CENSUS: 5DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:ADMINISTRATOR, Nikki Von Jena.TIME COMPLETED:
03:56 PM
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On December 06, 2022, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility for an unannounced required annual with emphasis on infection control. LPA Mixson was greeted and granted entry by Facility Manager, Aisha Moss introduced self and stated the purpose of the visit.

Present in the facility are four residents and one caregiver. There are currently no cases of COVID-19 within the facility.

LPA Mixson met with Administrator, Nikki Von Jena toured the facility and made observations pertaining to the facility's infection control measures. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning, disinfecting provisions, and the proper use of face coverings. LPA Mixson observed sufficient signage pertaining to hand washing and cough and cover procedures.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities.

LPA Mixson later discussed infection control practices and procedures with Administrator.

An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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