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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424320
Report Date: 01/31/2022
Date Signed: 01/31/2022 12:49:34 PM

Document Has Been Signed on 01/31/2022 12:49 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:FAUSTINA CARE CENTERFACILITY NUMBER:
366424320
ADMINISTRATOR:LAYGO, RUFINAFACILITY TYPE:
735
ADDRESS:24888 STANDING ROCK RDTELEPHONE:
(760) 961-0188
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: 4DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Rufina LaygoTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 01/31/2022 at 11:45 AM, unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrator Rufina Laygo and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator Laygo. Administrator Laygo reported that Mitigation Plan was submitted 02/19/2021. LPA Brown observed the facility having Covid-19 signages throughout the facility for cough etiquette, proper hand washing procedure and social distancing. Administrator Laygo accompanied LPA Brown on a tour of the inside and outside of the facility and LPA Brown observed that the two (2) and a half (1/2) resident bathrooms have paper towels and hand soap.

LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, and isolation gowns but no face shields/goggles. LPA Brown advised the facility to look online for item missing from their PPE supply kit, as Community Care Licensing (CCL) and Inland Regional Center (IRC) may not have these items all the time to supply them with.

LPA Brown went over the various recommended training for facility staff with Administrator Laygo in relation to COVID-19 and LPA Brown confirmed through Employee Training Logs that all staff were trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities.

*** Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: FAUSTINA CARE CENTER
FACILITY NUMBER: 366424320
VISIT DATE: 01/31/2022
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The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients for COVID-19, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their clients regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted with Administrator Rufina Laygo and a copy of this report (LIC 809) was provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
LIC809 (FAS) - (06/04)
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