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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426105
Report Date: 10/15/2021
Date Signed: 10/15/2021 02:45:37 PM

Document Has Been Signed on 10/15/2021 02:45 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:MEMBERS CLUB WINCHESTERFACILITY NUMBER:
336426105
ADMINISTRATOR:STIEN BAWENGANFACILITY TYPE:
735
ADDRESS:34827 VINEYARD GREEN CT.TELEPHONE:
(951) 926-7920
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 4CENSUS: 4DATE:
10/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Stein BawenganTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jennifer Semin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility via telephone. LPA met with administrator Stien Bawengan and advised her of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only.
LPA went over COVID-19 best practices for infection control and prevention with Ms. Bawengan who is successfully incorporating the facility's Mitigation Plan. Clients have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for local fire department has been updated.
LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the central entry point for convenience. LPA observed a storage area for storing all PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer supply and is inaccessible to clients. LPA observed an pre-made isolation cart that is dedicated for an isolation room, along with a trash can to put inside and outside of an isolation room.
LPA inquired as to if staff have been fit tested for N95 masks, and Ms. Bawengan stated their staff have not been fit tested yet. LPA will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive clients, and N95 masks only needing to be worn when a client is COVID-19 positive or under observation while awaiting test results. Additionally, all staff and clients have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA discussed Provider Information Notice (PIN) PIN-21-10-ASC, which contains resources for getting staff fit tested for N95 masks, with Ms. Bawengan.
An exit interview was conducted, and this report was discussed and provided to Ms. Bawengan along with a copy of LIC9102 TA Advisory Note.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
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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