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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423729
Report Date: 11/22/2022
Date Signed: 12/02/2022 09:16:56 AM

Document Has Been Signed on 12/02/2022 09:16 AM - 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:SEGURA'S HOME IIFACILITY NUMBER:
336423729
ADMINISTRATOR:THRASH, JENNETTEFACILITY TYPE:
735
ADDRESS:19378 SPIRIT TRAIL DRIVETELEPHONE:
(951) 780-8727
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 4CENSUS: 1DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator, Jennette ThrashTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit on 10/24/2022 at 01:20 p.m. in order to conduct an annual visit with a focus on infection control. LPA met with Administrator, Jennette Thrash, who was informed of the purpose of the visit. At the time of the visit there were (1) staff and (0) residents present. The resident was on an outting.

LPA proceed to conduct a walk through of the facility's interior and exterior. LPA observed there was a central entry point where screenings are conducted 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 to 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.

The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility. 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. Staff have also been FIT tested for an N95 respiratory.

LPA observed the medications were locked and the resident has a 30 day supply of medication. LPA observed the safe in the garage where fire arms are being kept.

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided to Administrator, Jennette Thrash.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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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