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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880899
Report Date: 02/28/2023
Date Signed: 02/28/2023 03:00:45 PM

Document Has Been Signed on 02/28/2023 03:00 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:GREEN WILLOW HOME CAREFACILITY NUMBER:
361880899
ADMINISTRATOR:HILARIO, MELINDA CFACILITY TYPE:
740
ADDRESS:950 S WILLOW AVETELEPHONE:
(909) 835-8706
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 6DATE:
02/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Remedios Manalo, CaregiverTIME COMPLETED:
03:00 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Green Willow Home Care Facility to conduct an Annual Inspection with a focus on Infection Control. LPA was greeted and granted entry into facility by Caregiver, Remedios Manalo. LPA introduced self and stated the purpose of the visit. LPA signed in and had temperature taken. Staff contacted Administrator Rosemary Sumadsad who later arrived during the visit.

During the inspection, LPA interviewed staff pertaining to the facility's infection control measures and other health and safety concerns. LPA observed necessary signs posted in the facility, including signs related to COVID-19, which were in accordance with the Department's guidelines. Staff stated that the facility is equipped with sufficient PPE, hand hygiene supplies, and sufficient cleaning/disinfecting provisions. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, 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 of residents, and properly caring for residents 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.

Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, and no deficiencies were noted. An exit interview was conducted where this report was discussed and provided to Rosemary Sumadsad.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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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