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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423747
Report Date: 05/24/2022
Date Signed: 05/24/2022 12:19:29 PM

Document Has Been Signed on 05/24/2022 12:19 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:ROSS HOUSE, THEFACILITY NUMBER:
336423747
ADMINISTRATOR:ROSS, TERRIFACILITY TYPE:
735
ADDRESS:41758 LAURIE LANETELEPHONE:
(951) 652-2533
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 6CENSUS: 2DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Administrtaor- Terri RossTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Administrator Terri Ross, who was informed of the purpose of the visit. At the time of visit there was 2 staff and 2 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA advised administrator to post Covid-19 postings at the facility. A single entry point was designated where symptoms screenings and temperature checks occur daily. LPA advised Administrator to document temperatures for all visitors, residents, and staff. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. LPA advised Administrator to place hand-washing posters in both restrooms. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA advised administrator to obtain a sufficient 30-day supply of PPE equipment and keep in a designated place. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces. LPA advised administrator to have designated staff get N95 FIT tested.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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: ROSS HOUSE, THE
FACILITY NUMBER: 336423747
VISIT DATE: 05/24/2022
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LPA noticed both residents had appropriate furniture in their rooms. Room 3 was being as an extra room, and Room 4 was vacant with no furniture. Facility had 3 beds at the time of the visit and is licensed for a capacity of 6. Administrator stated that the facility is currently vendorized with Inland Regional Center for 4 residents. Administrator stated she is in the process of getting the appropriate furniture for Room 4 and designate on facility Plan of Operation that the facility is currently vendorized with Inland Regional Center for 4 residents.

There were no deficiencies noted at the time of the visit. An exit interview was conducted, and a copy of this report was reviewed and provided to facility Administrator, Terri Ross.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
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