<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426420
Report Date: 11/15/2022
Date Signed: 11/15/2022 03:37:59 PM

Document Has Been Signed on 11/15/2022 03:37 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:SANDY LODGE II CARE HOMEFACILITY NUMBER:
336426420
ADMINISTRATOR:FAVIE-RUTH JIMENOFACILITY TYPE:
740
ADDRESS:25890 WHITMAN RD.TELEPHONE:
(951) 679-3492
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY: 6CENSUS: DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Staff, Maria BasubasTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit on 11/15/2022 at 02:00 p.m. in order to conduct an annual visit with a focus on infection control. LPA met with Staff, Maria Basubas, who was informed of the purpose of the visit. LPA spoke with Favie Jimeno, Administrator over the phone during the time of the visit. At the time of the visit there were (2) staff and (4) residents present.

LPA proceed to conduct a walk through of the facility's interior and exterior. LPA observed there was a central entry point where screenings are conducted for facility visits. The facility has a 30-day supply of PPE equipment that is readily accessible to staff. The facility has a designated visitation area in the facility. LPA observed the resident bedrooms that would be used as isolation rooms. The resident bathrooms were observed to be clean and have the appropriate hand hygiene supplies such as hand sanitizer, soap, running water and paper towels. The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility and the isolation rooms. The staff have leave in case of contact or testing positive for COVID-19. The staff have been trained on how to properly don and doff the PPE equipment, and there is a plan of care in place to attend to those residents that would be in the isolation rooms.

The staff have not yet been FIT tested for an N95 respiratory. This will be documented on a technical advisory note. LPA also observed the facility using pill box and advised the administrator over the phone to discontinue the use of the pill boxes as this goes against CCR Title 22, Division 6 Chapter 08 Article 08, 87465(h)(5). This will be documented on a technical advisory note. The administrator will send the LPA the staff in-service to cease this practice. LPA also noted that (3) residents were currently receiving hospice services. The facility currently has a waiver for (2) residents. LPA spoke with Administrator over the phone and was informed that a waiver had been sent to the regional office (2) months ago. LPA will have administrator refax this request and document this on a technical advisory note.

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided to Staff, Maria Basubas.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4