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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426057
Report Date: 12/27/2022
Date Signed: 12/27/2022 03:00:50 PM


Document Has Been Signed on 12/27/2022 03:00 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:EASTVALE SENIOR HOME CAREFACILITY NUMBER:
336426057
ADMINISTRATOR:ADELAIDA BADILLOFACILITY TYPE:
740
ADDRESS:14394 HEALY LAKE STREETTELEPHONE:
(951) 356-5270
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 6DATE:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Licensee Adelaida BadilloTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Chitgian 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 met with Licensee Adelaida Badillo. At the time of the visit there were four (4) staff, and six (6) residents present.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient signage throughout the facility, sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, PPE supplies are sufficient, 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 a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the residents physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.


During the tour of the facility, LPA found that the garage was converted into an office room/staff area that includes office table, a couch, end table, lamp, daybed and chairs. The facility sketch floor plan has the garage labeled as a garage not a break or office room. Converting the garage into a break or office room poses a potential health, safety, or personal rights risk to persons in care. The facility will be issued a type B deficiency. LPA took pictures of the converted staff room in the garage.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Victoria ChitgianTELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EASTVALE SENIOR HOME CARE
FACILITY NUMBER: 336426057
VISIT DATE: 12/27/2022
NARRATIVE
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Based on the observations made during today’s visit, one (1) deficiencies was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D form, and the appeal rights were discussed and provided to Licensee Adelaida Badillo.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Victoria ChitgianTELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/27/2022 03:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: EASTVALE SENIOR HOME CARE
FACILITY NUMBER: 336426057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
87307. Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by converting the garage into a staff room/staff sleeping area that includes office table, a couch, end table, lamp, daybed and chairs. The facility sketch floor plan has the garage labeled as a garage not a staff room. Converting the garage into a staff room poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2023
Plan of Correction
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The licensee has agreed to read regulation 87307 entirely and send LPA self certify letter that the regulation was read and understood. The licensee has agreed to remove the staff room items from the garage. The licensee has agreed to convert the staff area in the garage back to a garage per the facility sketch. The licensee has agreed to send LPA pictures as proof that the garage has been converted back to a garage. The POC is due
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Victoria ChitgianTELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3