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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425398
Report Date: 03/24/2022
Date Signed: 03/24/2022 02:16:43 PM

Document Has Been Signed on 03/24/2022 02:16 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:ANNA'S PARK HAVENFACILITY NUMBER:
336425398
ADMINISTRATOR:ANNA ESTANIELFACILITY TYPE:
740
ADDRESS:3911 PARK AVENUETELEPHONE:
(951) 658-6223
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 6CENSUS: 4DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Anna Estaniel, LicenseeTIME COMPLETED:
02:28 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection with an emphasis on infection control.

LPA Gardner met with Licensee Anna Estaniel. Present in the facility during time of visit were 4 clients. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA Gardner toured the facility and made observations pertaining to the facility's infection control measures. LPA Gardner observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. LPA Gardner discussed infection control practices and procedures with Licensee.

An exit interview was conducted and a copy of this report was discussed with and provided to the Licensee.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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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