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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426226
Report Date: 12/22/2022
Date Signed: 12/22/2022 01:09:23 PM

Document Has Been Signed on 12/22/2022 01:09 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:BAYCARE HOUSE LLCFACILITY NUMBER:
336426226
ADMINISTRATOR:NOAH WANGAIFACILITY TYPE:
735
ADDRESS:27309 BIG HORN AVENUETELEPHONE:
(951) 306-1323
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 0DATE:
12/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:ADMINISTRATOR, NOAH WANGAI.TIME COMPLETED:
01:18 PM
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On December 22, 2022, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility for an unannounced required annual with emphasis on infection control. LPA Mixson was greeted and granted entry by Administrator, Noah Wangai introduced self and stated the purpose of the visit.
Present in the facility are (0) residents and two caregivers. There are currently no cases of COVID-19 within the facility. Administrator and staff are fully aware of the COVID 19 vaccination process and procedures.

LPA Mixson met with Administrator toured the facility and made observations pertaining to the facility's infection control measures. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and the 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, and cleaning and disinfection provisions are in adequate quantities.

LPA Mixson later discussed infection control practices and procedures with Administrator.

An exit interview was conducted and a copy of this report was provided to Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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