336425841-1-20-2023-18-AS-JARA-CN9R2A-20230120113801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425841
Report Date: 01/20/2023
Date Signed: 01/20/2023 11:38:19 AM

Document Has Been Signed on 01/20/2023 11:38 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:	SANDY LODGE CARE HOME		FACILITY NUMBER:	336425841
ADMINISTRATOR:	FAVIE-RUTH JIMENO		FACILITY TYPE:	740
ADDRESS:	25703 SANDY LODGE RD		TELEPHONE:	(951) 301-0692
CITY:	SUN CITY	STATE: CA	ZIP CODE:	92586
CAPACITY:	6	CENSUS: 4	DATE:	01/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Administrator, Favie Jimeno		TIME COMPLETED:	11:50 AM

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) Janira Arreola, made an unannounced visit on 1/20/2023 at 10:10 a.m. in order to conduct an annual visit with a focus on infection control. LPA met with Administrator, Favie Jimeno, who was informed of the purpose of the visit. At the time of the visit there were (4) staff and (4) residents present. LPA proceed to conduct a walk through of the facility's interior and exterior. LPA observed there was a central entry point for facility visits were screening and temperature checks occur for residents, staff and visitors. LPA observed COVID-19 postings at the facility. The facility has a 30-day supply of PPE equipment that is readily accessible to staff. LPA observed the resident bedrooms that would be used as isolation rooms. The resident bathrooms were observed to be clean and have the appropriate hand hygiene supplies such as hand sanitizer, and hand sanitizer. The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility and the isolation rooms. The staff have leave in case of contact or testing positive for COVID-19. The staff have been trained on how to properly don and doff the PPE equipment, and there is a plan of care in place to attend to those residents that would be in the isolation rooms. LPA was informed by administrator that staff have not been FIT tested for an N95 respiratory and advised administrator to have designated staff to attend to COVID positive residents to be fit tested. LPA observed that (2) restrooms in the facility did not have the paper towels to dry hands, and instead observed cloth towels. LPA advised staff to place paper towels for infection control purposes. , LPA advised staff to check supplies throughout the day.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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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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: SANDY LODGE CARE HOME	FACILITY NUMBER: 336425841
	VISIT DATE: 01/20/2023

NARRATIVE

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LPA observed the (2) cans of powdered bleach and (1) bottle of window cleaner in facility restroom that was unlocked. Staff stated they had just cleaned the restroom, and the cleaners are kept in a different area. LPA could smell bleach in the restroom. LPA had staff remove the products immediately and secure them in a locked area. No residents were in the restroom at the time this was observed. LPA will be issuing a technical advisory note for this.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where this report was reviewed and provided to Administrator, Favie Jimeno

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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