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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366405765
Report Date: 09/21/2022
Date Signed: 09/21/2022 01:39:30 PM


Document Has Been Signed on 09/21/2022 01:39 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:CASA COLINA CENTERS FOR REHABILITATION/PADUA VILLAFACILITY NUMBER:
366405765
ADMINISTRATOR:RODNEY PEEKFACILITY TYPE:
735
ADDRESS:22200 HIGHWAY 18TELEPHONE:
(760) 247-7711
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY:54CENSUS: 33DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Rodney PeekTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Natalie Ibarra made an unannounced visit to conduct an annual inspection, with emphasis on infection control. LPA met with Administrator Rodney Peek and explained the purpose of today’s visit. Administrator accompanied LPA on a tour of the facility.

LPA toured the facility and made observations pertaining to the facility’s infection control measures. LPA observed signage throughout the facility for proper cough etiquette, proper hand washing procedure, and/or social distancing guidelines. The residents have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. Facility has sufficient hand hygiene supplies, cleaning, and disinfecting supplies. Staff working at the facility were all properly wearing face masks. The facility has a full thirty (30) day supply of PPE such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer. LPA observed one central entry point and a sign-in has been designated for screening that includes a vaccination verification/negative COVID test check, temperature check, and symptom check. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. LPA observed no health and safety concerns at the time of visit and the facility is meeting operational requirements.
No deficiencies were cited during today’s visit

An exit interview was conducted, and a copy of this report was discussed and provided to Administrator Rodney Peek.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Natalie IbarraTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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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