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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413166
Report Date: 02/10/2022
Date Signed: 02/10/2022 11:32:28 AM

Document Has Been Signed on 02/10/2022 11:32 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:PRECIOUS MOMENTS IFACILITY NUMBER:
366413166
ADMINISTRATOR:DE GUZMAN, RAMON CHITOFACILITY TYPE:
735
ADDRESS:16748 UKIAH STREETTELEPHONE:
(760) 596-0378
CITY:VICTORVILLESTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 6DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Ramon Chito De Guzman TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Stephanie Williams 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 Williams identified herself to Administrator, Ramon Chito De Guzman, who was also informed of the purpose of the visit.

During the inspection, LPA Williams interviewed the Administrator regarding the facility's infection control measures and inspected the facility for regulatory compliance. The Administrator stated that the facility does not currently have a COVID-19 mitigation plan (LIC 808) on file. LPA Williams observed appropriate postings within the facility, including COVID-19 symptoms postings, which were in accordance with the Department's guidelines. LPA Williams observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA Williams observed that the facility staff were wearing face coverings. 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 also 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.

Furthermore, LPA Williams observed that the facility appeared to be meeting operational requirements. LPA Williams observed that all utilities and appliances were functioning properly and all passageways clear of obstruction, including emergency exits. The facility was equipped with sufficient food supply and emergency supplies. All areas of the facility, including client bedrooms and restrooms, appeared clean and in good repair. LPA Williams observed that medications and dangerous objects were kept inaccessible to clients in care. LPA Williams observed no apparent health and safety risks at the time of visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PRECIOUS MOMENTS I
FACILITY NUMBER: 366413166
VISIT DATE: 02/10/2022
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Based on interviews and observations made during today’s inspection, one technical violation was issued for the facility not ensuring a COVID-19 mitigation plan was on file and one technical advisory was provided for staff N-95 fit testing. An exit interview was conducted where this report was discussed and a copy of this report was provided to the Administrator at the conclusion of the inspection.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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