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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800461
Report Date: 03/29/2022
Date Signed: 03/29/2022 12:04:45 PM

Document Has Been Signed on 03/29/2022 12:04 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
, CA 92507
FACILITY NAME:SKIOMAH ROADFACILITY NUMBER:
361800461
ADMINISTRATOR:SHARDE CARR, ERICAFACILITY TYPE:
735
ADDRESS:13159 SKIOMAH ROADTELEPHONE:
(818) 309-7821
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 6CENSUS: 3DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Angel WilkinsTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility in order to conduct a required annual inspection, with an emphasis on infection control, due to the COVID-19 pandemic. LPA Williams identified herself to Staff Member, Angel Wilkins, who was also informed of the purpose of the visit. LPA Williams spoke with Administrator, Erica Carr, over the phone during the visit.

During the inspection, LPA Williams interviewed Carr regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA Williams observed appropriate postings in the facility, including COVID-19 symptoms postings and visitation policies, which were in accordance with the Department's guidelines. LPA Williams observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 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 and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms. LPA Williams was not screened for COVID-19 symptoms upon arrival to the facility and did not observe the staff member on duty wearing a face covering. The Administrator also confirmed that N-95 respirator fit testing has not been conducted for all staff members.

Furthermore, LPA Williams observed that the facility appeared to be meeting operational requirements. LPA Williams observed that all utilities and appliances were functioning properly. The facility was equipped with sufficient food supply and emergency supplies. All areas of the facility, including client bedrooms and restrooms, appeared clean and in good repair. LPA Williams observed that medications and dangerous
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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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
, CA 92507
FACILITY NAME: SKIOMAH ROAD
FACILITY NUMBER: 361800461
VISIT DATE: 03/29/2022
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repair. LPA Williams observed that medications and dangerous objects were kept inaccessible to clients in care. LPA Williams observed no apparent health and safety risks at the time of visit.

Based on interviews and observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and a copy of this report was provided to Wilkins at the conclusion of the inspection.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC809 (FAS) - (06/04)
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