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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880854
Report Date: 03/01/2022
Date Signed: 03/01/2022 01:55:11 PM

Document Has Been Signed on 03/01/2022 01:55 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:ALLWISE RESIDENTIAL HOMEFACILITY NUMBER:
331880854
ADMINISTRATOR:USON, MARIBELFACILITY TYPE:
740
ADDRESS:14299 POINTER LOOPTELEPHONE:
(951) 479-5293
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 6DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Wendell Uson-AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Ryan Gardner and Amy Goldenberg made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPAs met with Administrator Wendell Uson. Upon entry, LPAs learned there were two (2) staff and six (6) residents at the facility. There are currently no cases of COVID-19 within the facility.

During today's visit, LPAs toured the facility and made observations pertaining to the facility's infection control measures. LPAs observed proper signs throughout the facility, sufficient hand hygiene supplies, 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 PPE supplies are maintained, 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 plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

LPAs reviewed the facility personnel report summary and Guardian for criminal record clearance. The review found that one (1) of the two (2) staff did not have a criminal record clearance.

Based on the observations made during today’s visit, a deficiency was cited per Title 22, Division 6, of the California Code or Regulations. Please see LIC 809D. An exit interview to review this report was conducted and a copy of this report along with appeal rights was provided.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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Document Has Been Signed on 03/01/2022 01:55 PM - It Cannot Be Edited


Created By: Ryan Gardner On 03/01/2022 at 01:07 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: ALLWISE RESIDENTIAL HOME
FACILITY NUMBER: 331880854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(b)(1)(D)


This requirement is not met as evidenced by: (b)Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. (D) Any staff person, volunteer, or employee who has contact with the clients.
Deficient Practice Statement
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Based on interview with administrator and criminal record review, LPAs learned that S1 did not have criminal record clearance prior to employment. The licensee did not comply with the section cited above in 1 out of 2 staff present during this visit, which poses an immediate health, safety or personal rights risk to persons in care. Interview with S1 determined employment started two (2) months ago.
POC Due Date: 03/02/2022
Plan of Correction
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The administrator removed staff from facility upon LPAs review. Administrator is staying at facility to provide care in their absence. Administrator will review regulations sections cited and provide statement of understanding to CCL by POC due date.

*A civil penalty assessment accompanies this deficiency.
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:Karen Clemons
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


LIC809 (FAS) - (06/04)
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