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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366405765
Report Date: 12/15/2021
Date Signed: 12/15/2021 04:33:24 PM

Document Has Been Signed on 12/15/2021 04:33 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: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: 33DATE:
12/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rodney Peek, Vice President TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a case management visit related to facility COVID positive residents and staff. Facility currently has 3 staff and 7 resident that have tested positive for COVID. Facility has tracked 49 staff that have been fully vaccinated, 2 staff that received their first vaccination and are pending their second. One medical exception is on file and 8 religious exceptions of file for staff. There are 29 resident that are fully vaccinated, with 2 boosters and 4 unvaccinated. Of the 4 unvaccinated indicate, families have stated they do not want residents vaccinated. Staff currently are tested weekly as part of facility mass testing. Weekly meetings are held a the facility related to COVID with staff and weekly meetings, Task Force Meetings, are held in Pomona with medical staff, related to COVID. It is observed by LPA and Vice President states that all staff wear N95 mask and face shields while at the facility at all times. COVID postings are posted throughout the facility and facility staff tested LPA before entry of facility for temperature and questions were asked related to contact with anyone who has tested positive. Facility has dedicated staff of all residents that have been quarantined due to positive COVID results.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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