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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880526
Report Date: 02/16/2023
Date Signed: 02/16/2023 02:02:33 PM

Document Has Been Signed on 02/16/2023 02:02 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DEMOH ADULT HOME IFACILITY NUMBER:
361880526
ADMINISTRATOR:PATRICK, MICHAELFACILITY TYPE:
735
ADDRESS:13700 CYPRESS AVETELEPHONE:
(760) 596-4994
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 4DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Crystal Pedraza Direct Support StaffTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit to conduct an annual inspection focused on infection control. LPA met with Direct Support Person (DSP) Crystal Pedraza and explained the purpose of the visit. At the time of the visit, there was two (2) staff and two(2) clients present at the facility.

LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed proper signs posted throughout the facility, sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. 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 garage.

The facility has a plan in place which follows Community Care Licensing Division guidelines for testing, isolating and caring for residents with Covid-19 positive and/or exposures. There is a designated infection control lead person tasked with tracking all positive cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in effect, and that staff are trained in the proper use and disposal of PPE. The staff will contact the client's physician in the event of Covid-19, or related illnesses. The staff are responsible for cleaning and disinfecting the highly touched surface areas during their shift. All staff and clients are practicing all other infection control precautions, which minimize the risk of Covid-19 infection.

LPA completed a walk-through of the facilities interior and exterior and observed the garage had a counter with detergents and food items stored together, which may pose a potential health and safety risk to clients. LPA advised DSP of the potential risk, and DSP proceeded to separate the food items.

Based on the observations made during today’s visit, one (1) technical violation was issued per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report (LIC809) and LIC 9102 was provided to DSP Crystal Pedraza.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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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