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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700896
Report Date: 06/06/2022
Date Signed: 06/06/2022 03:28:59 PM

Document Has Been Signed on 06/06/2022 03:28 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MVP CAREHOMEFACILITY NUMBER:
342700896
ADMINISTRATOR:PURUGGANAN, EVELETH R.FACILITY TYPE:
735
ADDRESS:5914 WEDGEWOOD AVENUETELEPHONE:
(909) 384-2276
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Paz Yntela, DSP and Administrator, Eveleth R. PuruggananTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Paz Yntela, DSP and Sally Banagan, DSP, who contacted Administrator by phone and explained purpose of inspection. LPA observed Job Udi, DSP, to be leading a game of Bingo with (5) clients during the start of the inspection. LPA observed all staff to be wearing masks. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. Administrator, Eveleth R. Purugganan, arrived at 1:50 pm. The facility is a licensed level (4H) home and is vendorized through Alta California Regional Center.

LPA and DSP, Paz Yntela, toured the interior and exterior of the facility, including (4) private resident bedrooms, (2) shared resident bedroom, (2) bathrooms, kitchen, common areas, sanitation station next to laundry area, office and garage/storage area. LPA observed all areas toured to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. Inside temperature was observed to be 71* F. Fire extinguisher last serviced 1/15/2022. LPA observed locked toxins, medications and sharps and sufficient 2+day perishable/7+day non-perishable food. First aid kits on site. Smoke/ monoxide alarms in working order. Facility conducts quarterly fire drills. LPA observed paper towels, soap, sanitizer, and hand-washing posters, trash cans with lids in the bathrooms and sufficient PPE supply and incontinent products, activities, and books. LPA observed various Covid posters outside the front entrance and throughout the facility along with other required postings. Discussed vaccination status of residents/staff, eligibility for boosters and visitation protocols per PIN 22-07. All staff are cleared/associated. LPA and Administrator completed the Infection Control Domain portion of the annual tool. LPA reviewed (1) resident file and observed it to be current and organized.

LPA requested an updated copy of LIC500 and LIC308 by 6/13/22. Exit interview. There were no deficiencies observed during today's inspection.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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