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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880895
Report Date: 07/22/2022
Date Signed: 07/22/2022 09:57:28 AM

Document Has Been Signed on 07/22/2022 09:57 AM - 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:ATTENTIVE MANOR IIFACILITY NUMBER:
331880895
ADMINISTRATOR:PECK, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:31221 EL TORO RDTELEPHONE:
(760) 620-5915
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 6CENSUS: 5DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Irma Vazquez, CaregiverTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection, with emphasis on infection control. LPA was greeted by Caretaker Irma Vazquez and explained the purpose of today's visit and signed into the facility. There were 5 residents inside the facility. Licensee Matthew Siegel was present inside the facility at the time of visit.

During today’s visit, LPA toured the facility and made observations pertaining to the facility’s infection control measures. LPA observed proper signage throughout the facility, sufficient hand hygiene supplies, and sufficient cleaning and disinfecting provisions, but noted the facility was deficient in their 30-day supply of Personal Protective Equipment (PPE). Thus, a Technical Advisory was issued.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in 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. LPA noted through the infection control tool that Ms. Vazquez doesn't have a fit test for a N95 mask. LPA issued a Technical Advisory in relation to the fit test.

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 illness.

An exit interview was conducted, and a copy of this report was discussed with and provided to Mr. Siegel along with copies of the Technical Advisory's issued.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
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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