<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427430
Report Date: 11/17/2022
Date Signed: 11/17/2022 04:29:27 PM


Document Has Been Signed on 11/17/2022 04:29 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:RWINS HAVEN FOR THE ELDERLYFACILITY NUMBER:
336427430
ADMINISTRATOR:PERGANTIS, ANGELOFACILITY TYPE:
740
ADDRESS:4912 RED ROCK AVETELEPHONE:
(951) 525-3809
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY:6CENSUS: 5DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Alicia Pergantis, Administrator/LicenseeTIME COMPLETED:
04:30 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 11/17/2022 at 03:30 p.m. in order to conduct an annual visit with a focus on infection control. LPA met with Alicia Pergantis, Administrator, who was informed of the purpose of the visit. At the time of the visit there were (4) staff and (5) 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 posting at the facility. The facility has a 30-day supply of PPE equipment that is readily accessible for 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.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where this report was reviewed and provided to Alicia Pergantis, Administrator
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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 1