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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880980
Report Date: 10/11/2021
Date Signed: 10/11/2021 03:05:02 PM

Document Has Been Signed on 10/11/2021 03:05 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:MAMA ANGELINA COCONOCHOFACILITY NUMBER:
331880980
ADMINISTRATOR:GONZALEZ, MARIA ROSARIOFACILITY TYPE:
740
ADDRESS:862 PIKE DRIVETELEPHONE:
(951) 335-1239
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 6CENSUS: 6DATE:
10/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Leonardo Janolino, CaregiverTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control.

LPA Gardner met with Caregiver Leonardo Janolino. Present in the home during time of visit were 6 clients. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA Gardner toured the facility and made observations pertaining to the facility's infection control measures. LPA Gardner observed 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. LPA Gardner discussed infection control practices and procedures with Mr. Janolino.

During the inspection LPA Gardner observed medication left out on the counter in the kitchen not secured by a lock in a safe place, and a Type A deficiency was issued.

An exit interview was conducted and a copy of this report, was reviewed with and provided to Mr. Janolino along with the LIC809-D, and Appeal Rights.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
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 10/11/2021 03:05 PM - It Cannot Be Edited


Created By: Jesse Gardner On 10/11/2021 at 02:39 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: MAMA ANGELINA COCONOCHO
FACILITY NUMBER: 331880980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)


This requirement is not met as evidenced by: 87465(h)(2) Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication.
Deficient Practice Statement
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Based on LPA Gardner's observation of unlocked medication left on the counter, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2021
Plan of Correction
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Licensee agrees to review medication regulations with staff. Licensee will provide a statement of understanding signed by all staff that they understand the regulations and that medications must be locked at all times no later than close of business on 10/12/21.
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:Reyna Lacey
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2021


LIC809 (FAS) - (06/04)
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