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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336406665
Report Date: 09/01/2022
Date Signed: 09/01/2022 01:38:07 PM

Document Has Been Signed on 09/01/2022 01:38 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:BOUNDLESS CARE FOR THE ELDERLYFACILITY NUMBER:
336406665
ADMINISTRATOR:SANDRA CHOCOBARFACILITY TYPE:
740
ADDRESS:26086 SHADY OAK COURTTELEPHONE:
(951) 315-7997
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 4CENSUS: 4DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Licensee/Administrator, Sandra ChocobarTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility for the purpose of an annual inspection with focus on infection control. LPA met with Licensee/Administrator Sandra Chocobar, who was informed of the purpose of the visit.

LPA conducted a walk through of the interior and exterior of the facility. LPA observed resident bedrooms that would be used as isolation rooms. LPA observed proper signage posted throughout the facility promoting proper cleaning, social distancing, and hand washing for COVID-19.

Facility has a plan for isolating those who have or suspected to have COVID-19 and have a plan in place to clean, disinfect and attend to those in the isolation room. LPA observed hand hygiene supplies in facility restrooms such as hand sanitizer, access to water, hand soap, and paper towels. LPA observed hand washing signs in facility restroom.

LPA observed the facility's PPE supply, which was a sufficient 30-day supply, and observed facility PPE cart for COVID-19 isolation room. LPA also observed hand sanitizer and PPE at the facility entry point.

Licensee stated staff have been training in the proper usage of PPE supplies, and designated staff member has been N95 Fit tested. LPA was informed of staff COVID-19 leave and when staff can return to work after being positive. LPA was also informed of staffing contingency plan for COVID-19.

The facility has one central entry point with a symptoms screening and sign in process for visitors. Temperatures are taken and recorded for residents, staff, and visitors. There is also a designated visitation area for visitors at the facility.

LPA checked facility LIC610E and checked that resident emergency contacts have been updated. LPA checked staff members for background clearance.

No deficiencies were observed during the time of the visit. An exit interview was conducted where this report was reviewed and provided to Licensee/Administrator.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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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