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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600008
Report Date: 05/26/2022
Date Signed: 05/26/2022 05:40:28 PM

Document Has Been Signed on 05/26/2022 05:40 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:DOWNSTOWN VIFACILITY NUMBER:
374600008
ADMINISTRATOR:ELISSA CIAVERELLIFACILITY TYPE:
735
ADDRESS:2248 TIERRA VERDETELEPHONE:
(760) 599-9762
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 4CENSUS: 3DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:55 PM
MET WITH:Pamela Wingrow, CaregiverTIME COMPLETED:
05:50 PM
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 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Caregiver Pamela Wingrove. LPA met with Caregiver and explained the purpose of the visit. At the time of visit there were 1 staff and 3 clients present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer). Staff were also observed wearing appropriate face coverings (surgical masks). The facility has an adequate amount of personal protective equipment (PPE).

LPA provided PIN 21-10-ASC for the staff to be able to access FIT testing resources, and to be fitted.

The facility has a plan in place to monitor clients regularly for any changes in condition, which includes documented daily temperature checks once a day. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses.

An exit interview was conducted and a copy of this report was provided to Caregiver Pamela Wingrove.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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