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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425849
Report Date: 09/21/2021
Date Signed: 09/21/2021 12:00:24 PM

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:AFFORDABLE ASSISTED LIVINGFACILITY NUMBER:
336425849
ADMINISTRATOR:RUIZ, GEORGEFACILITY TYPE:
740
ADDRESS:28549 HEATHER GREEN WAYTELEPHONE:
(951) 301-4259
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY:6CENSUS: 4DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:George Ruiz, LicenseeTIME COMPLETED:
12:10 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 was granted entrance and accompanied on the inspection of home by Beatrice Ruiz, Caregiver. George Ruiz, Licensee returned to the home and met with LPA during the second half of the visit. Currently there are four residents in care. There are currently no cases of COVID-19 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. The facility has submitted a Mitigation Plan which details their plan relating to 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 to Mr. Ruiz.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
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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