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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425514
Report Date: 10/19/2022
Date Signed: 10/19/2022 03:05:33 PM

Document Has Been Signed on 10/19/2022 03:05 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
, CA 92507
FACILITY NAME:DAVIS RESIDENTIAL FACILITY-SHERIDANFACILITY NUMBER:
366425514
ADMINISTRATOR:YVONNE DAVISFACILITY TYPE:
735
ADDRESS:14798 SHERIDAN COURTTELEPHONE:
(760) 524-7806
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 3DATE:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Yvonne Davis, LicenseeTIME COMPLETED:
03:10 PM
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Licensing Program Analysts (LPAs) Rayshaun Nickolas and Amber Coleman made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPAs arrived and met with facility staff. Licensee Yvonne Davis would later arrive at the facility. LPAs was screened for COVID-19 symptoms and asked to sign-in upon arrival. Davis confirmed that there are currently no cases/exposures of COVID-19 within the facility.

During the inspection, LPAs conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPAs observed appropriate postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPAs observed the facility staff wearing face masks. 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, 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 (CCLD) guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents 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.

LPAs observed no apparent health and safety concerns at the time of visit. No deficiencies were cited during this visit An exit interview was conducted where this report was discussed, and a copy of this report was provided to Davis at the conclusion of the inspection.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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