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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424317
Report Date: 02/07/2023
Date Signed: 02/07/2023 09:46:38 AM

Document Has Been Signed on 02/07/2023 09:46 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:SAMUEL HOMEFACILITY NUMBER:
336424317
ADMINISTRATOR:SANDRA HERNANDEZFACILITY TYPE:
735
ADDRESS:41367 TRUMBLE COURTTELEPHONE:
(760) 289-6014
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY: 6CENSUS: 4DATE:
02/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:FACILITY MANAGER, STEPHANIE ILIVAS.TIME COMPLETED:
09:53 AM
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On February 7, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility for an unannounced required annual with emphasis on infection control.

LPA Mixson spoke with via telephone with Administrator introduced self and stated the purpose of the visit. LPA Mixson met with Facility Manager and toured the facility.

Present in the facility were three caregivers, three residents, and one resident was at the day program. There are currently no positive cases of COVID-19 within the facility. All staff are fully vaccinated and boosted.

During the tour LPA Mixson made observations pertaining to the facility's infection control measures. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and the proper use of face coverings.

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 Facility Manager.

An exit interview was conducted and a copy of this report was given to Facility Manager.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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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