336425958-11-9-2021-18-AS-CCON-C8LTLE-20211109134924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425958
Report Date: 11/09/2021
Date Signed: 11/09/2021 01:49:32 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:	AT SUNNY HILLS HOME CARE		FACILITY NUMBER:	336425958
ADMINISTRATOR:	ZANDER, SHELLEY		FACILITY TYPE:	740
ADDRESS:	26600 IRONWOOD AVE.		TELEPHONE:	(951) 924-3289
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	8	CENSUS: 8	DATE:	11/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Linda Thomas - Administrator		TIME COMPLETED:	02:00 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 Analysts (LPAs) Crystal Colvin and Venus Mixon arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPAs Colvin and Mixon met with Administrator Linda Thomas 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 Linda Thomas, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns) which LPA Colvin observed to be sufficient for a 30-day supply. LPA Colvin went over the various recommended training for facility staff with Administrator Linda Thomas 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. LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Linda Thomas informed LPA Colvin that at this time staff have not been fit tested and inquired about where to get resources for fit testing. 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. Additionally, most residents have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Colvin will be providing Licensee/Administrator with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

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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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: AT SUNNY HILLS HOME CARE	FACILITY NUMBER: 336425958
	VISIT DATE: 11/09/2021

NARRATIVE

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LPA Colvin went over the facility's schedule for checking inventory for hygiene supplies for residents as well as checking each resident's room individually to assess the need for restocking. Administrator Linda Thomas informed LPA Colvin that staff check resident rooms frequently to assess if more supplies are needed. LPA Colvin inquired about if the facility is still conducting COVID-19 surveillance testing of their unvaccinated staff members. Administrator Linda Thomas informed LPA Colvin that all staff are vaccinated, with the exception of one who is getting their first dose of the vaccine this week.

In addition to going over the facility's policy for testing staff and residents for COVID-19, LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Administrator Linda Thomas confirmed that staff are continuing to monitor residents’ symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility. LPAs Colvin and Mixon additionally observed a sign-in log for visitors, where their temperature is recorded as well as answers to screening questions.

An exit interview was conducted with Administrator Linda Thomas and a copy of this report and LIC9102 TA Advisory Note was provided.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

LIC809 (FAS) - (06/04)

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