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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408489
Report Date: 03/18/2022
Date Signed: 03/18/2022 12:08:28 PM

Document Has Been Signed on 03/18/2022 12:08 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:CATHEDRAL MANORFACILITY NUMBER:
336408489
ADMINISTRATOR:JOLI FRIAS VICENCIOFACILITY TYPE:
740
ADDRESS:31222 EL TORO ROADTELEPHONE:
(760) 202-7203
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 6CENSUS: 2DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Verly Frias - Assistant AdministratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Assistant Administrator Verly Frias 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:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Assistant Administrator Verly Frias, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in the front of the facility where guests are screened, as well as in the resident bathrooms. LPA Colvin observed the facility to not have an adequate supply of face masks, both surgical and N95. LPA Colvin will be issuing the facility a Technical Advisory Note instead of a deficiency, as the facility has enough in supply for current daily use. LPA Colvin went over the various recommended training for facility staff with Assistant Administrator Verly Frias in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Assistant Administrator Verly Frias informed LPA Colvin that at this time staff have only been trained on donning/doffing PPE. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CATHEDRAL MANOR
FACILITY NUMBER: 336408489
VISIT DATE: 03/18/2022
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LPA Colvin will be providing Verly with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

LPA Colvin inquired about if the facility is screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Assistant Administrator Verly Frias confirmed that residents are being screened daily. LPA Colvin observed a sign-in sheet at the front door of the facility, and confirmed that visitors and staff are being screened for symptoms prior to entering the facility. LPA Colvin inquired about the facility's policy for checking on residents who are in isolation and positive for COVID-19. Assistant Administrator Verly Frias stated that though they have not had any resident positive cases at the facility, if they did they would check on them and assess their symptoms daily. LPA Colvin will be issuing a Technical Advisory Note as the current recommendation is to check on positive residents at least every 4 hours. LPA Colvin is not issuing a deficiency as the facility does not and has not had any positive residents.

An exit interview was conducted with Assistant Administrator Verly Frias and a copy of this report and LIC9102 TA Advisory Notes were provided. LPA Colvin additionally dropped off nine (9) COVID-19 testing kits at the facility during today's inspection.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
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