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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800216
Report Date: 01/31/2022
Date Signed: 01/31/2022 03:30:50 PM

Document Has Been Signed on 01/31/2022 03:30 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:HILEA HOMEFACILITY NUMBER:
361800216
ADMINISTRATOR:MORENO, DARLENEFACILITY TYPE:
735
ADDRESS:14032 OLEMA RDTELEPHONE:
(760) 503-0124
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 4CENSUS: 4DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Brandon Andrews and Jasmine ZetinoTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility 01/31/2022 at 01:15 PM to conduct an annual inspection, with emphasis on infection control. LPA Brown was greeted and granted entrance by caregiver Brandon Andrews and LPA explained the purpose of today's visit. Administrator Darlene Moreno was contacted and unable to come to the facility for the inspection. Caregiver Andrews accompanied LPA Brown on a tour of the inside and outside of the facility. Caregivers Jasmine Zetino and Melinda Corbin arrived during the visit for the afternoon shift.

During today’s visit, LPA Brown made observation pertaining to the facility’s current infection control measures. LPA Brown observed a screening area, proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and clients for COVID-19, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor client regularly for any changes in condition and to subsequently notify the client’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

LPA Brown reviewed the facility’s Covid-19 training for facility staff and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. LPA Brown asked Administrator Moreno via telephone at around 01:30 PM as to if staff have been fit tested for N95 masks, and Administrator Moreno informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a deficiency during today's inspection for staff not being fit tested for N95 masks due to the facility currently have a COVID-19 positive staff. *** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
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 3
Document Has Been Signed on 01/31/2022 03:30 PM - It Cannot Be Edited


Created By: Melody Brown On 01/31/2022 at 03:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HILEA HOME
FACILITY NUMBER: 361800216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
130

Licensee has provided all staff who are working with Covid 19 positive residents with fit testing for N95 respirators. This practice has a health and safety impact that includes, but is not limited to personal rights, buildings and grounds and responsibility to providing care and supervision.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not providing all staff with fit testing for N95 respirators which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2022
Plan of Correction
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Licensee will submit proof of N95 Fit test of all staff by POC due date to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022


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: HILEA HOME
FACILITY NUMBER: 361800216
VISIT DATE: 01/31/2022
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Additionally, per file review, all residents are vaccinated, and most staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown will be providing the facility with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

An exit interview was conducted with caregiver Jasmine Zetino and a copy of this report (LIC809), LIC809D and Appeal Rights were provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
LIC809 (FAS) - (06/04)
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