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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800441
Report Date: 01/19/2022
Date Signed: 01/19/2022 03:59:30 PM

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:SPECIAL ANGELS GROUP FACILITIES INCFACILITY NUMBER:
361800441
ADMINISTRATOR:COLLIER, JAZMINFACILITY TYPE:
740
ADDRESS:1053 N BRIERWOOD AVETELEPHONE:
(909) 543-7604
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:6CENSUS: 6DATE:
01/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Kristina Serna, caregiverTIME COMPLETED:
11:03 AM
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On 1/19/22 Licensing Program Analyst (LPA) Shaunte Henry arrived at the facility to conduct an unannounced annual inspection with an emphasis on infection control. LPA met with Kristina Serna, explained the nature of the inspection and was granted entry into the facility. There are currently 6 residents living at the facility. As of this date there are no positive COVID-19 cases or individuals with COVID-like symptoms present in the facility.

LPA toured the facility with the administrator. There is one point of entry for routine COVID-19 symptoms screening that is initiated for all residents, staff and visitors. Signs have been posted throughout the facility, which indicates the visitor policy and proper hand washing, cough/sneeze etiquette, and social distancing practices. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents. LPAs observed a sufficient supply of hand hygiene, cleaning and disinfecting items. LPA observed a sufficient supply of Personal Protective Equipment (PPE) that included surgical masks, N-95 masks, face shields, gloves, gowns, etc. The facility has a designated infection control person who is responsible for ensuring that the facility is compliance with infection control practices. The facility has a COVID mitigation plan in place, which outlines testing requirements, isolating/quarantining positive COVID-19 cases, proper cleaning/sanitizing/disinfecting and monitoring of individuals for COVID-like symptoms. The facility is aware that it is mandatory that Community Care Licensing (CCL) is contacted if anyone tests positive for COVID-19.

According to California Code of Regulations, Title 22, Division 6, there were no deficiencies observed or cited during this visit. An exit interview was conducted where this report was discussed with and provided to Kristina Serna.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
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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