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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366405765
Report Date: 10/21/2021
Date Signed: 10/21/2021 10:56:30 AM

Document Has Been Signed on 10/21/2021 10:56 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
RIVERSIDE, CA 92507
FACILITY NAME:CASA COLINA CENTERS FOR REHABILITATION/PADUA VILLAFACILITY NUMBER:
366405765
ADMINISTRATOR:RODNEY PEEKFACILITY TYPE:
735
ADDRESS:22200 HIGHWAY 18TELEPHONE:
(760) 247-7711
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 54CENSUS: 34DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Rodney PeekTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Jennifer Semin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility via telephone. LPA met with administrator Rodney Peek and Administrative Case Manager Noemi Barron and advised them of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only.
LPA went over COVID-19 best practices for infection control and prevention with administrators who are successfully incorporating the facility's Mitigation Plan. Clients have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels.
LPA observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for local fire department has been updated.
LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the central entry point for convenience. LPA observed several storage areas for storing all PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer supply and is inaccessible to clients. LPA observed multiple built in storage areas throughout the facility that will be designated for isolation wing, along with a trash cans to put inside and outside of an isolation room/wing.
LPA inquired as to if staff have been fit tested for N95 masks, and all staff have been fit tested for N95 masks and a record is being kept. Additionally, the majority of the clients and staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

An exit interview was conducted, and this report was discussed and provided to the administrator.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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