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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412271
Report Date: 08/29/2022
Date Signed: 08/29/2022 11:16:00 AM


Document Has Been Signed on 08/29/2022 11:16 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:ERWIN LAKE ELDERLY CAREFACILITY NUMBER:
366412271
ADMINISTRATOR:YVONNE KURZEJAFACILITY TYPE:
740
ADDRESS:2052 STATE LANETELEPHONE:
(909) 585-4004
CITY:BIG BEAR CITYSTATE: CAZIP CODE:
92314
CAPACITY:6CENSUS: 6DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Marijane Tan, Care StaffTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility in order to conduct a required annual inspection, with an emphasis on infection control, due to the COVID-19 pandemic. LPA was met by care provider Marijane Tan. LPA phoned Administrator Yvonne Kuzeja. Staff verified there are no active and/or suspected Covid-19 cases in the facility.

During the inspection, LPA interviewed Tan regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed that the facility was equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 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 and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. The facility has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

LPA observed that the facility appeared to be meeting operational requirements. LPA Bueno observed that all utilities and appliances were functioning properly. All areas of the facility, including restrooms, appeared clean and in good repair.

LPA Bueno observed no apparent health and safety risks at the time of visit. An exit interview was conducted where a copy of this report was reviewed and provided to care staff Marijane Tan.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
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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