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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423700
Report Date: 04/05/2022
Date Signed: 04/05/2022 03:02:36 PM


Document Has Been Signed on 04/05/2022 03:02 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:A GOOD SAMARITANFACILITY NUMBER:
336423700
ADMINISTRATOR:SALOTE TUPOUFACILITY TYPE:
740
ADDRESS:3839 STRONG STREETTELEPHONE:
(951) 742-5188
CITY:RIVERSIDESTATE: CAZIP CODE:
92501
CAPACITY:6CENSUS: 3DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator, Tupou Salote TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA)’s, Janira Arreola and David Cuevas made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA's were greeted and granted entry by Administrator,Tupou Salote who was informed of the purpose of the visit. At the time of visit there was 2 staff and 3 residents present. The facility currently has zero positive or suspected Covid-19 cases. LPA did not observe any pools or bodies of water within the premises. LPA's were informed that no weapons or ammunition is maintained at the home.

During today's visit, LPA’s toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA's observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer) in all restrooms (3 restrooms.)

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility also has a designated infection control lead and cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies. No deficiencies noted at the time of visit.

An exit interview was conducted, and a copy of this report was reviewed and provided to facility Administrator, Tupou Salote.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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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