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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881183
Report Date: 10/21/2022
Date Signed: 10/21/2022 10:28:47 AM


Document Has Been Signed on 10/21/2022 10:28 AM - 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:MIRIAM'S HOMECAREFACILITY NUMBER:
361881183
ADMINISTRATOR:GAD, ENRICOFACILITY TYPE:
740
ADDRESS:1635 HAMPSHIRE RDTELEPHONE:
(818) 912-0178
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92404
CAPACITY:6CENSUS: 6DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Miriam Nauseda, LicenseeTIME COMPLETED:
10:35 AM
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LPA Amber Coleman (LPA Coleman) and LPA Anna Bueno LPA Bueno made an unannounced visit to Miriam's Homecare Facility for the purpose of conducting a Annual Inspection for Infection Control. Staff opened the door greeted LPA's and invited them inside. Staff member was observed to be wearing a mask. Staff member allowed LPA's to sign in where the COVID station was equipped with sanitizer and thermometer for temperature. LPA Bueno and LPA made introductions and stated the purpose of the visit. Staff introduced herself and stated she was the Licensee for the facility.

Licensee and LPA's toured the facility and the backyard. The backyard has two bodies of water; a in ground pool and jacuzzi. LPA Coleman observed the pool to be locked by a surrounding gate. The gate is equipped with two locks top and bottom. The jacuzzi was covered and locked. LPA's observed and tested both fire alarms and carbon monoxide alarms to be in working order. LPA's observed a fire extinguisher with last inspection be 3/16/22. LPA's also observed each entryway equipped with exit signs and alarms. Licensee reported the capacity is 6 residents and the current census is 6. LPA's met with a second staff member (S1) who was working on changing and preparing the client's for breakfast. LPA. Licensee showed LPA's where the medicine and sharps are kept. Both were observed to be in locked cabinets. Licensee showed LPA's food pantry and refrigerator. They were well stocked with sufficient perishable and non perishable items as required. LPA Coleman observed proper signages throughout the facility. LPA Coleman also observed two first aid kits hung on the hallway wall. The facility has sufficient PPE, paper and disinfection supplies.

Based on the observations made during today’s visit, a technical advisory was issued. LPA encouraged staff to have an N95 Fit Test conducted to prevent the spread of infection. No citations were issued during the visit. An exit interview to review this report was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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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