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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800424
Report Date: 03/15/2022
Date Signed: 03/22/2022 02:29:10 PM

Document Has Been Signed on 03/22/2022 02:29 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
, CA 92507
FACILITY NAME:EASTVALE SENIOR HOME CARE IIFACILITY NUMBER:
331800424
ADMINISTRATOR:BADILLA, ADELAIDAFACILITY TYPE:
740
ADDRESS:14318 PINTAIL LOOPTELEPHONE:
(951) 220-7354
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 4DATE:
03/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Rea Alin, Assistant AdministratorTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Amy Goldenberg made an announced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA was met at the door by a caregiver and granted entry into the home. She is wearing a mask. LPA is informed that there are no COVID positive individuals in the home. The facility has an approved mitigation plan on file with this agency. Precautionary Covid-19 postings are present at the front door and at the entry point. There is one entry point designated where sign in procedures and screening will occur. The staff are temperature screening visitors upon entry into the facility. LPA is informed that there are currently four (4) residents in the home.

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and has a limited supply of Personal Protective Equipment (PPE). LPA discussed the availability of additional PPE supplies to the facility at the time of this visit and advised the facility representatives to contact our office in the event additional supplies are necessary. During this inspection LPA made observation of liquid seizure medication, laxative medication and Tums located in an unlocked cabinet in the kitchen, and a makeshift sleeping quarters located in the garage area of the facility.

Based on observations made during today’s inspection, the following deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative along with appeal rights.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
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 03/22/2022 02:29 PM - It Cannot Be Edited


Created By: Amy Goldenberg On 03/15/2022 at 01:34 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
, CA 92507

FACILITY NAME: EASTVALE SENIOR HOME CARE II
FACILITY NUMBER: 331800424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/16/2022
Section Cited

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The following requirements shall apply to medications which are centrally stored:Centrally stored medicines shall be kept in a safe and locked place...The facility has failed to meet this requirement
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as evidenced by LPA observation of liquid seizure medication, laxative medication and tums located in an unlocked cabinet during this inspection. This poses a risk to the health and safety of residents in care.
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cited and provide a statement of understanding of the regulatory requirement by POC due date.
Type A
03/16/2022
Section Cited

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All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...The facility has failed to meet this requirement as evidenced by LPA observation of
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a makeshift sleeping quarters located in the garage are aof the facility. This poses a risk to the health and safety of indivuals in care.
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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:Nedra Brown
LICENSING EVALUATOR NAME:Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022


LIC809 (FAS) - (06/04)
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