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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408220
Report Date: 05/09/2022
Date Signed: 05/09/2022 10:44:51 AM

Document Has Been Signed on 05/09/2022 10:44 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
, CA 92507
FACILITY NAME:INSPIRATIONS HOME CARE IIFACILITY NUMBER:
336408220
ADMINISTRATOR:GARCIA, NOELIAFACILITY TYPE:
740
ADDRESS:2800 COTTAGE DRTELEPHONE:
(951) 549-1693
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6CENSUS: 6DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Noelia Garcia TIME COMPLETED:
11:00 AM
NARRATIVE
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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. LPA met with caregiver Yajaira Villalba and Administrator/LIcensee Noelia Garcia arrived during the visit. LPA advised her of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only.
LPA went over COVID-19 best practices for infection control and prevention with Ms. Garcia, who is successfully incorporating the facility's Mitigation Plan. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA discussed the need to have paper towels on stands or mounted. Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants shall be inaccessible to residents. At 8:59am LPA observed cleaning/disinfecting supplies under the bathroom sink and were accessible to residents. This poses an immediate health and safety risk to residents in care. A deficiency will be cited. 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 at the central entry point for convenience. LPA observed a minimal supply of PPE items. Gloves, face shields, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer supply and is inaccessible to residents. LPA discussed the need to procure additional gowns and N95 masks. LPA will issue a Technical Assistance notice.LPA and Ms. Garcia discussed creating a box or similar for all PPE necessary to be dedicated for isolation room, along with trash cans to put inside and outside of an isolation room. LPA will issue a Technical Assistance notice.LPA inquired as to if staff have been fit tested for N95 masks, and Ms. Garcia stated her, and her staff have not yet been fit tested. LPA and Ms. Garcia discussed Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks. LPA will issue a Technical Assistance notice.
An exit interview was conducted where this report and LIC809D was discussed and provided to Ms. Garcia.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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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Document Has Been Signed on 05/09/2022 10:44 AM - It Cannot Be Edited


Created By: Jennifer Semin On 05/09/2022 at 10:23 AM
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
, CA 92507

FACILITY NAME: INSPIRATIONS HOME CARE II
FACILITY NUMBER: 336408220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)


This requirement is not met as evidenced by: At 8:59am LPA observed Ajax and simple green cleaning/dinfecting supplies under the bathroom sink and accessible to residetns in caer.
Deficient Practice Statement
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The following shall be stored inaccessible to residents with dementia:
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
POC Due Date: 05/10/2022
Plan of Correction
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LIcensee shall read the ergulation in its entirety, train staff on this regulation, submit a statement of understanding and training log to CCL by the POC due date of 5/10/2022.

LIcensee moved and placed these items in a locked cabinet while LPA was present.
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:Efren Malagon
LICENSING EVALUATOR NAME:Jennifer Semin
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022


LIC809 (FAS) - (06/04)
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