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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412126
Report Date: 05/09/2022
Date Signed: 05/09/2022 11:58:04 AM

Document Has Been Signed on 05/09/2022 11:58 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 VFACILITY NUMBER:
336412126
ADMINISTRATOR:GARCIA, NOELIAFACILITY TYPE:
740
ADDRESS:2865 COTTAGE DRTELEPHONE:
(951) 898-1425
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6CENSUS: 6DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Noelia GarciaTIME COMPLETED:
12:10 PM
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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 Administrator/LIcensee Noelia Garcia. 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.
Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by: At 11:01am LPA observed sleeping quarters set up in resident master bedroom closet. This poses a 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 11:58 AM - It Cannot Be Edited


Created By: Jennifer Semin On 05/09/2022 at 11:25 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 V
FACILITY NUMBER: 336412126

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)
PERSONAL ACCOMIDATIONS AND SERVICES: Living accomidations and grounds shall be related to the facility function. The facility shallbe large enough to provide comfortable living accomidations and privacy for all residents, staff and others who may reside in the facility.

This requirement is not met as evidenced by:At 11:01am LPA observed sleeping quarters set up in the master bedroom closet
Deficient Practice Statement
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 LPA observed a mattress, shelving unit and personal items of staff menber in the master bedroom closet.



POC Due Date: 05/10/2022
Plan of Correction
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Licensee shall ensure that staff and residents sleep in designated areas only. Proof of understanding shall be submitted in writing to CCL by the POC due date of 5/10/2022.

LIcensee moved all staff personal items from the closet.
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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