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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426468
Report Date: 10/17/2022
Date Signed: 10/17/2022 11:50:32 AM

Document Has Been Signed on 10/17/2022 11:50 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
RIVERSIDE, CA 92507
FACILITY NAME:FAMILYCARE HOME - MONTARAFACILITY NUMBER:
336426468
ADMINISTRATOR:JOSE KOFACILITY TYPE:
740
ADDRESS:9781 VIA MONTARATELEPHONE:
(951) 924-0181
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 4DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Joseph Ko, Co-AdministratorTIME COMPLETED:
11:55 AM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA arrived at approximately 8:45 AM and utilized hand sanitizer. The LPA met with Co-Administrator, Joseph Ko, and informed him of the purpose of her visit. There are currently no cases of COVID-19 within the facility.

During today's visit, the LPA toured the home and made observations pertaining to the facility's infection control measures. The LPA 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 and cleaning and disinfection provisions are in adequate quantities. The facility has a Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report in place and is pending review from the Department. The plan establishes guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, 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 resident's regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

The following deficiencies were observed: no symptom screening for visitors, staff or residents; no daily temperature checks; no sign in policy in place; no signs indicating the visitor's policy; chairs in television room were not physically distanced; no 95 Fit testing; no sick leave training for staff; and insufficient Personal Protective Equipment (PPE). This poses a potential health, safety or personal rights risk to persons in care.

An exit interview to review this report was conducted with Ko and a copy of this report was provided, along with appeal rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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 10/17/2022 11:50 AM - It Cannot Be Edited


Created By: Stephanie Torres On 10/17/2022 at 10:57 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
RIVERSIDE, CA 92507

FACILITY NAME: FAMILYCARE HOME - MONTARA
FACILITY NUMBER: 336426468

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observationn interview, and record review, the licensee did not comply with the section cited above. LPA observed no symptom screening for visitors, staff or residents; no daily temperature checks; no sign in policy in place; no signs indicating the visitor's policy; chairs in living room were not physically distanced; no 95 Fit testing; no sick leave training; and insufficient PPE. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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Administrator stated he will review the facility's COVID-19 Mitigation Plan and put into place the appropriate practices. He agreed to submit a statement of certification once completed.
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:Deborah Mullen
LICENSING EVALUATOR NAME:Stephanie Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022


LIC809 (FAS) - (06/04)
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