336427429-11-4-2022-18-AS-JARA-CKUUAB-20221104152429

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336427429
Report Date: 11/04/2022
Date Signed: 11/04/2022 03:24:42 PM

Document Has Been Signed on 11/04/2022 03:24 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:	ST. PEREGRINE'S GUEST HOME		FACILITY NUMBER:	336427429
ADMINISTRATOR:	BAYAUA, JEROME E		FACILITY TYPE:	735
ADDRESS:	29804 ANDROMEDA STREET		TELEPHONE:	(858) 722-6448
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY: 6		CENSUS:	DATE:	11/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Licensee/ Administrator, Jerome Bayaua		TIME COMPLETED:	03:35 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 Analyst (LPA) Janira Arreola, made an unannounced visit on 11/04/2022 at 01:30 p.m. in order to conduct an annual visit with a focus on infection control. LPA met with Licensee/ Administrator, Jerome Bayaua, who was informed of the purpose of the visit. At the time of the visit there were (1) staff and (4) residents present. LPA proceed to conduct a walk through of the facility's interior and exterior. LPA observed there was a central entry point where screenings are conducted for facility visits. LPA observed COVID-19 postings at the facility. The facility has a 30-day supply of PPE equipment that is readily accessible for residents and staff. The facility has a designated visitation area in the facility. LPA observed the resident bedrooms that would be used as isolation rooms. The resident bathrooms were observed to be clean and have the appropriate hand hygiene supplies such as hand sanitizer, soap, running water and paper towels. The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility and the isolation rooms. The staff have leave in case of contact or testing positive for COVID-19. The staff have been trained on how to properly don and doff the PPE equipment, and there is a plan of care in place to attend to those residents that would be in the isolation rooms. LPA was informed by the administrator that (1) staff member has not yet been tested for the N95 respirator. LPA informed where the administrator can get this done and requested to be informed when this is conducted for the staff. LPA advised the administrator that this is an OSHA regulation that the department is enforcing in licensed facilities. LPA was informed by Administrator that the facility does not currently have a Monkey Pox infection control plan. The administrator stated that they can provide one to the LPA by November 11, 2022. Technical advisory note was documented for this. *CONTINUED ON LIC809-C PAGE*

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

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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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: ST. PEREGRINE'S GUEST HOME	FACILITY NUMBER: 336427429
	VISIT DATE: 11/04/2022

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LPA observed unlocked chemicals under the kitchen sink, LPA also observed unlocked laundry detergent in the laundry room, and gardening tools such as gardening shears and hoe in the facility backyard that were accessible to clients. There were some gym weights that were accessible to clients in the backyard as well as gym equipment. Administrator was able to secure these items immediately. LPA was informed by administrator that (2) clients do their own laundry, LPA advised administrator to lock the detergent and supervise the residents when they are doing their laundry. LPA also advised the administrator to have a locked shed in the facility yard to keep gym weights and gardening equipment, or to keep it secured in the facility garage. At the time of the visit there were no residents in the areas where these items were found. LPA documented on a technical advisory note. LPA advised the administrator to rid the facility of clutter, such as (2) extra t.v.'s that were observed in the upstairs lobby and an extra bed in the upstairs loft area. LPA document technical advisory note for this.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where this report was reviewed and provided to Licensee/ Administrator, Jerome Bayaua.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC809 (FAS) - (06/04)

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