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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604338
Report Date: 10/28/2022
Date Signed: 10/28/2022 03:14:36 PM

Document Has Been Signed on 10/28/2022 03:14 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:MOLLY'S HOUSEFACILITY NUMBER:
374604338
ADMINISTRATOR:POWELL, DUSHAWN A.FACILITY TYPE:
735
ADDRESS:15260 VILLA SIERRA RDTELEPHONE:
(951) 473-3692
CITY:VALLEY CENTERSTATE: CAZIP CODE:
92082
CAPACITY: 4CENSUS: 4DATE:
10/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Staff, Jennifer PowellTIME COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit on 10/24/2022 at 01:15 p.m. in order to conduct an annual visit with a focus on infection control. LPA met with staff Jennifer Powell, who was informed of the purpose of the visit. At the time of the visit there were (2) staff and (2) residents present.

LPA proceed to conduct a walk through of the facility's interior and exterior. LPA observed there was a central entry point where screenings are conducted for facility visits. LPA observed COVID-19 postings throughout the facility. The facility has a 30-day supply of PPE equipment that is readily accessible for residents and staff. The facility has a designated visitation area in the facility. LPA observed the resident bedrooms that would be used as isolation rooms. The resident bathrooms were observed to be clean and have the appropriate hand hygiene supplies such as hand sanitizer, soap, running water and paper towels.

The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility and the isolation rooms. The staff have leave in case of contact or testing positive for COVID-19. The staff have been trained on how to properly don and doff the PPE equipment, and there is a plan of care in place to attend to those residents that would be in the isolation rooms. LPA was informed that the staff have not yet been FIT tested for an N95 respiratory. LPA will document technical advisory note for this.

LPA reviewed the LIC500 and reviewed the Guardian roster to ensure all staff had been cleared. Staff #1 (S1) had 2 profiles open on Guardian which stated "in process" and "fingerprints not taken". LPA reviewed Guardian and found that all inquires on the staff's background were in process. The LPA will document an 809-D page for the deficiency and document plan of correction. LIC421BG will be documented with civil penalty amount of $500.

An exit interview was conducted where this report, LIC809-D page, and appeal rights were reviewed and provided to staff Jennifer Powell.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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 10/28/2022 03:14 PM - It Cannot Be Edited


Created By: Janira Arreola On 10/28/2022 at 02:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOLLY'S HOUSE
FACILITY NUMBER: 374604338

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
80019(e)(1)
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview, and record review, the licensee did not comply with the section cited with S1 who has a "in process" background, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2022
Plan of Correction
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The Licensee will ensure that all staff are cleared prior to hiring and call into CPMB to inquire why the background is still processing. The licensee shall write a written statement stating this fact.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022


LIC809 (FAS) - (06/04)
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