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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880915
Report Date: 05/25/2021
Date Signed: 05/25/2021 10:53:04 AM

Document Has Been Signed on 05/25/2021 10:53 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:HICKORYWOOD CARE HOMEFACILITY NUMBER:
331880915
ADMINISTRATOR:CARLSON, DAVID JFACILITY TYPE:
740
ADDRESS:1650 HICKORYWOOD LANETELEPHONE:
(951) 795-1623
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 6CENSUS: 0DATE:
05/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:David CarlsonTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Jennifer Semin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility via telephone. LPA met with licensee/administrator David Carlson and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

LPA went over COVID-19 best practices for infection control and prevention with Mr. Carlson who is successfully incorporating the facility's Mitigation Plan. Residents will have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for local fire department has been updated.

LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the hall closet. LPA observed a minimal supply of PPE readily available for use. LPA discussed with Mr. Carlson the need to increase the amount of on hand PPE items including gloves, face shields, gowns, surgical masks and N95 masks. Disinfectant and hand sanitizer supply is stored in the laundry room and inaccessible to residents. LPA and Mr. Carlson discussed creating a box, or similar, to have a supply of PPE ready that would be dedicated for isolation room, along with a trash can to put outside of an isolation room.

An exit interview was conducted and a copy of this report was discussed and provided to Mr. Carlson.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2021
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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