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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424322
Report Date: 09/21/2021
Date Signed: 09/21/2021 01:42:21 PM

Document Has Been Signed on 09/21/2021 01:42 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:D&D HOME #3FACILITY NUMBER:
336424322
ADMINISTRATOR:DOUGLAS P BEATTY IIIFACILITY TYPE:
735
ADDRESS:28769 GOLDEN DAWN DRIVETELEPHONE:
(951) 301-8572
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY: 6CENSUS: 4DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Douglass Beatty, LicenseeTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Deborah Mullen made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. The LPA, met by Licensee, Douglas Beatty. Currently there are 4 residents in care. Currently the facility does not have any active COVID-19 cases within the facility.

During today's visit, the LPA toured the facility and made observations pertaining to the facility's infection control measures. The LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and 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, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control.
Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided Mr. Beatty.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Deborah Mullen
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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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