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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400553
Report Date: 08/17/2021
Date Signed: 08/17/2021 02:44:54 PM

Document Has Been Signed on 08/17/2021 02:44 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
RIVERSIDE, CA 92507
FACILITY NAME:MOJAVE NARROWS RANCH HOMEFACILITY NUMBER:
366400553
ADMINISTRATOR:ENTZ, BRIANFACILITY TYPE:
735
ADDRESS:14599 RIVERSIDE DRIVETELEPHONE:
(760) 242-6945
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 4DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Peggy AmesTIME COMPLETED:
02:55 PM
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Licensing Program Analysts (LPAs) Melody Brown and Natalie Gayoso made an unannounced visit to the facility to conduct an annual inspection, with emphasis on infection control. LPAs were greeted and granted entrance by Direct Support Professional (DSP) Peggy Ames and explained the purpose of today's visit. DSP Ames accompanied LPAs on a tour of the inside and outside of the facility. Administrator Brian Entz was contacted and unable to come to the facility for the inspection.

During today’s visit, LPAs made observation pertaining to the facility’s current infection control measures. LPAs observed a screening area, proper signage throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and adequate 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, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. 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 to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, no deficiencies were cited.
An exit interview was conducted, and a copy of this report was provided to DSP Peggy Ames.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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