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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603415
Report Date: 01/20/2023
Date Signed: 01/20/2023 12:41:09 PM

Document Has Been Signed on 01/20/2023 12:41 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:VERSATILE RESIDENTIAL CAREFACILITY NUMBER:
374603415
ADMINISTRATOR:ANNABELLE BARRETOFACILITY TYPE:
735
ADDRESS:1830 GOODWIN DRIVETELEPHONE:
(760) 536-3265
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 6CENSUS: 6DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:FACILITY MANAGER, VANGIE LORENZO.TIME COMPLETED:
12:46 PM
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On January 20, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the above facility for an unannounced required annual with emphasis on infection control. LPA Mixson was greeted and granted entry by Facility Manager, Vangie introduced self and stated the purpose of the visit.

Present in the facility were six residents and two caregivers. There are currently no cases of COVID-19 within the facility.

LPA Mixson toured the facility and made observations pertaining to the facility's infection control measures. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and the proper use of face coverings.

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, and cleaning and disinfection provisions are in adequate quantities.

LPA Mixson later discussed infection control practices and procedures with Facility Manager.

An exit interview was conducted and a copy of this report, along with a copy of the LIC 811, was given to Facility Manager.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
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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