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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426224
Report Date: 06/23/2022
Date Signed: 06/23/2022 03:04:05 PM


Document Has Been Signed on 06/23/2022 03:04 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:DOVE TREE MANORFACILITY NUMBER:
366426224
ADMINISTRATOR:SOSNOVSKY, EVA FEFACILITY TYPE:
740
ADDRESS:3991 DOVE TREE AVE.TELEPHONE:
(909) 441-7891
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY:6CENSUS: 5DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Russell BernardoTIME COMPLETED:
03:06 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a required annual inspection with an emphasis on infection control. LPA identified herself to care staff Leonardo Dolliente. Staff Russell Bernardo arrived shortly and verified that the facility currently has no active and/or suspected COVID-19 cases.

During the inspection, LPA interviewed care staff regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed appropriate postings in the facility, including COVID-19 symptoms and infection control postings, which were in accordance with the Department's guidelines. LPA observed that the facility was also 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 also has a plan in place to monitor residents regularly for any changes in condition and to notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

During the inspection, LPA did not observe private accommodations for live-in staff. LPA interviewed staff who stated that they live in the facility for 5 days. Refer to LIC809D for deficiency cited. A technical advisory was provided to remind staff the importance wearing properly fitting face coverings.

An exit interview was conducted where this report was discussed, and a copy of this report was provided to Russell Bernardo at the conclusion of the inspection.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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Document Has Been Signed on 06/23/2022 03:04 PM - It Cannot Be Edited

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
, CA 92507


FACILITY NAME: DOVE TREE MANOR
FACILITY NUMBER: 366426224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and staff interview, the Licensee did not comply with the section cited above. LPA did not observe private accomodations for live-in staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2022
Plan of Correction
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Licensee shall provide private accomodations for staff and submit proof to CCLD regional office by the end of POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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