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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408630
Report Date: 09/16/2022
Date Signed: 09/16/2022 01:33:12 PM

Document Has Been Signed on 09/16/2022 01:33 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:HAZEL GUEST HOME IIFACILITY NUMBER:
336408630
ADMINISTRATOR:HAZEL A. BUTARDOFACILITY TYPE:
740
ADDRESS:24629 SUPERIOR AVENUETELEPHONE:
(951) 247-9355
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 6CENSUS: 4DATE:
09/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Myrna DeJesus, CaregiverTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection, with emphasis on infection control. LPA was greeted by Caregiver Myrna DeJesus and explained the purpose of today's visit. There were 4 residents inside the facility at the time of visit.

LPA toured the facility and made observations pertaining to the facility’s infection control measures. LPA observed proper signage throughout the facility, sufficient hand hygiene supplies, and sufficient cleaning and disinfecting provisions. The 30 days supply of Personal Protective Equipment (PPE) was deficient. Administrator Hazel Abella ordered sufficient supply for residents at time of visit.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in 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 clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas.

The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illness.

An exit interview was conducted, and a copy of this report was discussed with and provided to Ms. Abella.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
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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