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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881019
Report Date: 03/11/2022
Date Signed: 03/11/2022 12:47:44 PM


Document Has Been Signed on 03/11/2022 12:47 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:WILDWOOD CANYON VILLAFACILITY NUMBER:
361881019
ADMINISTRATOR:BARRERA, WENDYFACILITY TYPE:
740
ADDRESS:33951 COLORADO STTELEPHONE:
(909) 446-0405
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY:130CENSUS: 66DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Business Services Director Priscilla MancillaTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 03/11/2022 at 09:30 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Business Services Director Priscilla Mancilla and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Business Services Director Priscilla Mancilla and per file review, Mitigation Plan was submitted 07/27/2021. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility's and observed that resident bathrooms have paper towels and hand soap. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, isolation gowns, face shields/goggles.

LPA Brown went over the various recommended training for facility staff with Business Services Director Priscilla Mancilla in relation to COVID-19 and Business Services Director Priscilla Mancilla reported that all staff were trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.



LPA Brown inquired as to if staff have been fit tested for N95 masks, and Business Services Director Priscilla Mancilla informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a deficiency for this item due to the facility recently have a COVID-19 positive staff last 02/25/2022, and N95 masks needs to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Also, LPA Brown observed that most residents and staff have been vaccinated and are practicing other COVID-19 precautions. *** Continuation in LIC809C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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: WILDWOOD CANYON VILLA
FACILITY NUMBER: 361881019
VISIT DATE: 03/11/2022
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LPA Brown informed Business Services Director Priscilla Mancilla the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

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. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their residents for COVID-19, when and how to isolate/quarantine resident, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their residents regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

LPA Brown reviewed Personnel Report (LIC500) and facility personnel report summary and observed that Staff 1 (S1) is not associated at the facility due to Staff 1 separation date reported last 04/01/2020. Business Services Director Priscilla Mancilla reported that S1 separated from the facility last 2020, and S1 was rehired last 07/2021 and added that they will correct the issue today. LPA Brown will be issuing a technical violation for failure to associate employee at the facility.

During the visit, LPA Brown requested staff vaccination records and on 03/11/2022 at 11:00 AM, LPA Brown observed no booster vaccination record for Staff 2 at the facility. Business Services Director Priscilla Mancilla reported that Staff 2 will submit staff booster vaccination record/religious exemption this weekend and Business Services Director Priscilla Mancilla confirmed that Staff 2 had no booster vaccination record available at the facility during the visit. LPA Brown will be issuing a deficiency for failure to keep records of Worker’s Vaccination which can pose potential risk to residents in care.

An exit interview was conducted with Business Services Director Priscilla Mancilla and a copy of this report (LIC809), LIC809D, LIC9102 AN Technical Violation and Appeal Rights were discussed and provided.


SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/11/2022 12:47 PM - It Cannot Be Edited

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: WILDWOOD CANYON VILLA
FACILITY NUMBER: 361881019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
130

Licensee has provided all staff who are working with Covid-19 positive residents with fittesting for N95 respirators. This practice has a health and safety impact, that includes but is not limited to personal rights, buildings and grounds and responsibility for providing care and supervision.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the Licensee did not comply with the section cited above because Licensee did not provide all staff who are working with Covid-19 residents with fit testing for N95 respirators which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2022
Plan of Correction
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Licensee stated that they will submit proof that all staff have completed N95 respirator fit test by POC due date to LPA Brown.
Type B
Section Cited
HSC
121125,120140,120276


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that personal rights of persons in care to live in safe, healthy, comfortable home failed to comply with reporting and personnel requirements and engaged in conduct inimical to the health, welfare, and safety of persons in care in that licensee did not verify Staff 2's booster vaccination/exemption by maintaining a record as required by State Public Officer Order of December 22, 2021 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
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Licensee stated that they will submit S2's proof of booster vaccination/exemption to LPA Brown by POC due date and will also update Staff 2 Vaccination file by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4