336424485-7-19-2022-18-AS-CCON-CGGVKN-20220719163036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336424485
Report Date: 07/19/2022
Date Signed: 07/19/2022 04:30:56 PM

Document Has Been Signed on 07/19/2022 04:30 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:	MORENO VALLEY GUEST HOME II		FACILITY NUMBER:	336424485
ADMINISTRATOR:	NOYA JACKSON		FACILITY TYPE:	735
ADDRESS:	15370 LAS ROSAS AVENUE		TELEPHONE:	(951) 242-1316
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92551
CAPACITY: 6		CENSUS: 4	DATE:	07/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Michael Curry - Administrator		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Administrator Michael Curry and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed: Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Michael Curry, and discussed the facility's Mitigation Plan. LPA Colvin informed the Administrator that Licensing does not have a copy of this document, but that a new Infection Control Plan is required and advised the Administrator to review the recent Provider Information Notices (PINs) for direction. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. Upon entering the facility, LPA Colvin had her temperature taken and signed in on the visitor log. LPA Colvin viewed the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns). LPA Colvin did not observe the facility to have isolation gowns. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection as these items are only required if the facility has a COVID positive resident. The PPE supplies that the facility does have are accessible to staff in the staff room. LPA Colvin went over the various recommended training for facility staff with Administrator Michael Curry in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. Administrator Michael Curry informed LPA Colvin that staff have not yet been fit tested for N95 masks. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Administrator Michael Curry confirmed that staff are continuing to monitor residents’ symptoms.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

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: MORENO VALLEY GUEST HOME II	FACILITY NUMBER: 336424485
	VISIT DATE: 07/19/2022

NARRATIVE

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Other:
During LPA Colvin's inspection, LPA Colvin observed that Administrator Michael Curry was not on the facility's staff roster, which LPA Colvin had pulled from Guardian this morning. LPA Colvin additionally opened Guardian while at the facility and confirmed that the Administrator has clearance, but is not associated to the facility.

Having someone working at the facility without completion of transferring clearance results in civil penalties in the amount of $100 per day, per individual. Since this is the facility's first citation for this in the last 12 months, the maximum amount of days they can be cited is 5. LPA Colvin will be issuing civil penalties in the maximum amount of $500 ($100 per day x 5 days) during today's inspection, as Administrator Michael Curry has been working at the facility for over one year.

An exit interview was conducted with Administrator Michael Curry and a copy of this report, LIC9102 Technical Advisory Notes, LIC809D, LIC421(BG) and appeal rights were provided.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/19/2022 04:30 PM - It Cannot Be Edited

Created By: Crystal Colvin On 07/19/2022 at 04:14 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MORENO VALLEY GUEST HOME II	FACILITY NUMBER: 336424485
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(e)(2)

Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 staff member (Administrator), which poses an immediate safety risk to persons in care. LPA Colvin observed that Administrator MIchael Curry has approved background clearance, but has not had the clearance trasnferred to the facility.
	POC Due Date: 07/20/2022
	Plan of Correction
1 2 3 4	Licensee agrees to have the staff member's background clearance trasnferred to the facility by Plan of Correction date of 7/20/22. This may be done by submitting the documents in person at the Regional Licensing Office or online through Guardian. Licensee to self-certify to LPA Colvin once complete.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Joel Esquivel

LICENSING EVALUATOR NAME:

Crystal Colvin

LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC809 (FAS) - (06/04)

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