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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880508
Report Date: 07/22/2022
Date Signed: 07/22/2022 03:56:06 PM

Document Has Been Signed on 07/22/2022 03:56 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:EMPATHYFACILITY NUMBER:
331880508
ADMINISTRATOR:BANSODE, HEMALATAFACILITY TYPE:
740
ADDRESS:17312 RIVA RIDGETELEPHONE:
(951) 323-0536
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 5DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Karen Hidalgo, StaffTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA arrived at approximately 02:30 PM, signed in and utilized hand sanitizer. The LPA met with Staff, Karen Hidalgo, and informed her of the purpose of her visit. Administrator, Hemalata Bansode, was notified of the visit via telephone. There are currently no cases of COVID-19 within the facility.

During today's visit, the LPA toured the home and made observations pertaining to the facility's infection control measures. The LPA observed sufficient cleaning and disinfecting provisions and 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 cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a COVID-19 Plan in place which is pending review from the Department. The facility also has a screening station in place.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations. An exit interview to review this report was conducted with Hidalgo and a copy of this report was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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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