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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603665
Report Date: 07/06/2022
Date Signed: 07/06/2022 02:36:52 PM


Document Has Been Signed on 07/06/2022 02:36 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:DEVON PLACE HOME CAREFACILITY NUMBER:
374603665
ADMINISTRATOR:MARK LOOFACILITY TYPE:
740
ADDRESS:1814 DEVON PLACETELEPHONE:
(760) 941-1818
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 6DATE:
07/06/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Nester Blay, CaregiverTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit related to COVID-19. LPA met with Caregiver Nester Blay and explained the purpose of the visit. Blay contacted Administrator Mark Loo via telephone and LPA spoke with him regarding today's visit and the facility's COVID-19 protocols.

During today's visit, LPA toured the facility and observed COVID-19 posters which are in accordance with Department regulations. LPA observed a sign-in station at the front entry along with a plentiful supply of hand sanitizer for visitors to utilized upon arrival. LPA also observed a temporal thermometer at the front entry to be utilized for the measurement of visitor's temperatures. Signs are posted on the front door that visitors exhibiting signs and symptoms of COVID-19 must reschedule their visit. Signs are also posted that all visitors must wear a mask. Facility bathrooms are equipped with paper towels, soap, hand sanitizer, and a hand washing poster. The bathroom in bedroom #1 did not initially have a posted hand washing poster but one was placed at LPA's request during the visit. Residents who share a bedroom have their beds situated at least six (6) feet apart as required by the Department. Residents are observed for any change in condition, screened for temperature changes and oxygen saturation at least once daily. Resident blood pressures are also monitored daily. LPA observed two (2) of two (2) staff and one (1) of six (6) residents to be wearing a mask.

No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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