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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425056
Report Date: 07/19/2022
Date Signed: 09/07/2022 01:23:22 PM

Document Has Been Signed on 09/07/2022 01:23 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
, CA 92507
FACILITY NAME:MANITOBA RESIDENTIAL CAREFACILITY NUMBER:
336425056
ADMINISTRATOR:CHARISSE MCCOYFACILITY TYPE:
735
ADDRESS:1703 MANITOBA CIRCLETELEPHONE:
(951) 531-8952
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 5CENSUS: 3DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Beverly J. Clark, Caregiver-DesigneeTIME COMPLETED:
01:30 PM
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7/19/22-Licensing Program Analyst (LPA) Amy Goldenberg arrived to the facility in attempt to conduct an annual required. LPA contacted Administrator Charisse McCoy after knocking and receiving no answer. LPA was advised that there was a positive COVID 19 test resulted for a staff and that they are reporting to CCL via the duty line. No one is in the home or available to meet with LPA at this time due to the COVID outbreak. Visit attempt ended.

8/2/22-LPA Goldenberg attempted a visit. LPA knocked on the door. No one answered,

9/7/2022- Licensing Program Analysts (LPA) Amy Goldenberg made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA is informed that there are no positive cases of Covid-19 at this time. Three (3) clients live in this home. None are present during this visit.

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and a 30 day supply of Personal Protective Equipment (PPE). 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 infection control.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
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
, CA 92507
FACILITY NAME: MANITOBA RESIDENTIAL CARE
FACILITY NUMBER: 336425056
VISIT DATE: 07/19/2022
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The facility continues to monitor client regularly for any changes in condition, and notify the client's physician and emergency personnel in the event the client presents any COVID-19 symptoms. Emergency food supply is in place. LPA inquired about fit testing and found that the employees have not been fit tested for N95 respirators. Technical assistance provided during this visit.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
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