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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880980
Report Date: 10/31/2022
Date Signed: 10/31/2022 11:59:22 AM

Document Has Been Signed on 10/31/2022 11:59 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:MAMA ANGELINA COCONOCHOFACILITY NUMBER:
331880980
ADMINISTRATOR:GONZALEZ, MARIA ROSARIOFACILITY TYPE:
740
ADDRESS:862 PIKE DRIVETELEPHONE:
9513351239
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 6CENSUS: 6DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Michelle Fisher, CaregiverTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 10:40 AM, LPA was met by Caregiver Michelle Fisher and explained the purpose of the visit. Present in the facility during time of visit were two (2) staff as well as six (6) residents. Licensee Maria Gonzalez arrived during the inspection. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient signage throughout the facility, insufficient 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, PPE supplies are maintained at the facility, cleaning and disinfection provisions are in adequate quantities, and that staff are not 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 maintain a plan to monitor resident(s) 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.

Based on the observations made during today’s visit, four (4) Technical Assistance Advisories, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview to review this report was conducted and a copy of this report was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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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