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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880730
Report Date: 11/08/2021
Date Signed: 11/08/2021 04:19:49 PM

Document Has Been Signed on 11/08/2021 04:19 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:MORNING MIST HOMECAREFACILITY NUMBER:
331880730
ADMINISTRATOR:SANASINH, SIMMFACILITY TYPE:
740
ADDRESS:7902 NATOMA STTELEPHONE:
(949) 233-1643
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 5DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nenita Valle, Caregiver TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Amy Goldenberg made an unannounced 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 is informed that there are no COVID positive individuals in the home. The facility has an approved mitigation plan on file with this agency. There is screening of visitors upon entry into the facility.

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. The facility continues to monitor client regularly for any changes in condition, and notify the client's physician and emergency personnel in the event the client presents any COVID-19 symptoms.

Based on observations made during today’s inspection, the facility has a deficiency in the area of Fire Safety. LPA observation of a couch and twin bed in a closet revealed through discussion with caregivers that the area is utilized a rest/sleeping quarters. This room is not designated as a bedroom as part of the approved fire clearance. This space has no window and this is an immediate health and safety risk to the persons in the home. Please see LIC809 D for deficiency 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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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 11/08/2021 04:19 PM - It Cannot Be Edited


Created By: Amy Goldenberg On 11/08/2021 at 12:07 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
RIVERSIDE, CA 92507

FACILITY NAME: MORNING MIST HOMECARE
FACILITY NUMBER: 331880730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All Facilities shall be maintained in conformity with the regulations adopted by the state and fire Marshal for the protection of life and property against fire and panic.
-This requirement is not met as evidenced by: LPA observation of a couch and twin bed in a closet. Upon discussion with the caregivers, the closet is used as a caregivers rest area. This space is not designated as part of the fire clearance to be utilized as a sleeping/resting quarters. The space has no window.
Deficient Practice Statement
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Based on LPA observation the licensee did not comply with the section cited above which poses an immediate health, safety risk to those utilizing the closet.
POC Due Date: 11/08/2021
Plan of Correction
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The use of the closet as a rest/sleeping area shall cease immediately, removing the immediate risk of persons in the facility. Licensee to remove the bed and couch from the closet immediatly. Licensee plan is to utilize 24 hour awake staff until a room approved as part of the fire clearance as a bedroom can be utilized for caregiver use. Licensee to submit a statement of understanding for the regulation cited and plan for 24 hour awake staff staffing schedule by POC due date 11/09/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021


LIC809 (FAS) - (06/04)
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