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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425633
Report Date: 08/05/2022
Date Signed: 08/05/2022 04:15:23 PM

Document Has Been Signed on 08/05/2022 04:15 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:NELSON ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
336425633
ADMINISTRATOR:ALAN ALIAN JR.FACILITY TYPE:
735
ADDRESS:2216 FIELDING RD.TELEPHONE:
(951) 224-9068
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 5DATE:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Lead caregiver, Victorio EstevesTIME COMPLETED:
04:15 PM
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On 08/05/2022, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection, with an emphasis on infection control only. LPA Mixson met with Lead caregiver, Victorio Esteves, and advised of the purpose of the visit.

Present in the facility were 6 residents and 4 caregivers. There are currently no cases of COVID-19 within the facility.

LPA Mixson observed residents have hand sanitizer available to them, and the resident bathrooms were stocked with liquid soap and paper towels.
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 Lead-caregiver.

An exit interview was conducted, and a copy of this report, along with the LIC 811 was provided to Lead-caregiver.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
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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