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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800233
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:51:59 AM


Document Has Been Signed on 01/31/2023 11:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:CARMEL CARE HOMEFACILITY NUMBER:
361800233
ADMINISTRATOR:DENSEN, ROMMELFACILITY TYPE:
740
ADDRESS:11971 4TH AVETELEPHONE:
(760) 488-1828
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:10CENSUS: 6DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Licensee Densen RomellTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit to conduct an annual inspection with a focus on infection control. LPA met with Licensee Romell Densen and explained the purpose of the visit. At the time, there were two (2) staff and six (6) resident present.

LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. The entrance of the facility has a check in process for staff and visitors that includes a temperature and symptom check. LPA observed postings for handwashing and proper cough etiquette throughout. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towels). LPA observed a thirty (30) day supply of Personal Protective Equipment (PPE) which includes gloves, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer. PPE was stored in the laundry area.

The facility staff has a plan in place to manage Covid-19 symptoms, which includes staff monitoring residents regularly for any changes in condition and daily symptom checks. The facility will contact the resident's physician in the event of any Covid-19 related illnesses. The facility staff are responsible for cleaning and disinfecting the highly touched surface areas during their shift multiple times a day. All staff and residents are practicing all other infection control precautions, which minimize the risk of them contracting Covid-19.

LPA toured the facilities interior and exterior and explained the importance of maintaining a tidy and hazard-free facility at all times.

Based on the observations made during today’s visit, no deficiencies were issued per Title 22, Division 6, of the California Code of Regulations. One(1) Technical Assistance was provided for the untidy state of the backyard and dining area which had items and supplies observed throughout.

An exit interview was conducted, and a copy of this report (LIC809) and LIC 9102 was provided to Licensee Romell Densen.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Victoria ChitgianTELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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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