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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424311
Report Date: 01/20/2023
Date Signed: 01/20/2023 12:44:31 PM

Document Has Been Signed on 01/20/2023 12:44 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL MERLOTFACILITY NUMBER:
366424311
ADMINISTRATOR:MILES, WILTONFACILITY TYPE:
735
ADDRESS:21295 MERLOT LNTELEPHONE:
(760) 240-9976
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 4CENSUS: 4DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Tia Johnson- StaffTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit to conduct an annual inspection focused on infection control. LPA met with staff Tia Johnson and explained the purpose of the visit. At the time of the visit, there were two(2) staff and 4(four) clients present.

LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. The entrance of the facility has a check in process for visitors that includes a temperature check and a symptom check. LPA observed proper signs posted throughout the facility, sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towels). LPA observed a limited supply of Personal Protective Equipment (PPE) which included gloves, disinfectant, and hand sanitizer Two(2) boxes of N95 masks were available. PPE was stored in the closet. No gowns or surgical face masks were available. The facility was informed to obtain a 30-day supply of PPE.

The facility has a plan in place which follows Community Care Licensing Division guidelines for testing, isolating and caring for clients with COVID-19 positive and/or exposures. There is a designated infection control lead person tasked with tracking all positive cases, cleaning and disinfection provisions are in effect. The facility staff monitors clients regularly for any changes in condition and daily symptom checks. The staff will contact the client's physician in the event of any COVID-19 related illnesses. The staff are responsible for cleaning and disinfecting the highly touched surface areas during their shift. All staff and clients are practicing all other infection control precautions, which minimize the risk of them contracting COVID-19.

LPA completed a walk-through of the facilities interior and exterior. Based on the observations made during today’s visit, one(1) technical advisory (LIC 9102) was given for the limited PPE supply available.

An exit interview was conducted, and a copy of this report (LIC809) was provided to staff Tia Johnson.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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