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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880563
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:23:18 PM

Document Has Been Signed on 11/17/2022 03:23 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:RWINS ELDERLY'S HAVENFACILITY NUMBER:
331880563
ADMINISTRATOR:PERGANTIS, ALICIAFACILITY TYPE:
740
ADDRESS:4960 RED BLUFF RDTELEPHONE:
(714) 398-9566
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 6CENSUS: 5DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Alicia Pergantis, Administrator/LicenseeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit on 11/17/2022 at 01:50 p.m. in order to conduct an annual visit with a focus on infection control. LPA met with Alicia Pergantis, Administrator, who was informed of the purpose of the visit. At the time of the visit there were (3) staff and (5) 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. The staff have also been FIT tested for an N95 respiratory.

LPA noted that the meat mallet was left out on the counter of the kitchen during the tour of the facility. LPA advised staff and licensee to keep this item locked as well for staff and resident safety. This will be documented on a technical advisory note.Staff also moved a kitchen knife that was left air drying in the kitchen on the dish rack. No residents were in the kitchen at the time this was witnessed. LPA advised staff to wipe it clean and put the knife in the locked drawer right away to avoid having an unsupervised knife in the dish rack. This will be documented on a technical advisory note.
*** CONTINUED ON 809-C PAGE**
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: RWINS ELDERLY'S HAVEN
FACILITY NUMBER: 331880563
VISIT DATE: 11/17/2022
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LPA noted that the contact sheet for the residents did not have the phone numbers listed for the resident #1 (R1). Staff was able to write in the residents contact information by the end of the visit. This will be documented on a technical advisory note.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where this report was reviewed and provided to Alicia Pergantis, Administrator
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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