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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800464
Report Date: 04/01/2022
Date Signed: 04/01/2022 01:21:49 PM

Document Has Been Signed on 04/01/2022 01:21 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:MASHBURN HOMES INCFACILITY NUMBER:
331800464
ADMINISTRATOR:MASHBURN, MARISSAFACILITY TYPE:
740
ADDRESS:853 PIKE DRTELEPHONE:
(951) 927-0611
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 5CENSUS: 4DATE:
04/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Melanie Soriano, CaretakerTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection with an emphasis on infection control.

LPA met with Caretaker Melanie Soriano. Present in the facility during time of visit were 3 clients, with 1 being at their day program. There are currently no cases of COVID-19 within the facility. Administrator Christopher Bundalin arrived during the visit.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA 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, cleaning and disinfection provisions are in adequate quantities. LPA later discussed infection control practices and procedures with Mr. Bundalin.

An exit interview was conducted, and a copy of this report was discussed with and provided to Mr. Bundalin.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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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