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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427431
Report Date: 11/08/2022
Date Signed: 11/08/2022 01:27:03 PM

Document Has Been Signed on 11/08/2022 01:27 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:4J'S ELDERLY CARE INCFACILITY NUMBER:
336427431
ADMINISTRATOR:GATUS, JONIEFACILITY TYPE:
740
ADDRESS:69272 TACOMA CTTELEPHONE:
(760) 656-1715
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 6CENSUS: 5DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:ADMINISTRATOR, JONIE GATUS.TIME COMPLETED:
01:33 PM
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On November 08, 2022, Licensing Program Analyst (LPA), Venus Mixson arrived at the above facility for an unannounced required annual with emphasis on infection control. LPA Mixson was greeted and granted entry by Administrator, Jonie Gatus introduced self and stated the purpose of the visit.

Present in the facility were 5 residents and 2 caregivers. There are currently no cases of COVID-19 within the facility.

LPA Mixson toured the facility and made observations pertaining to the facility's infection control measures. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and the proper use of face coverings. All residents have private rooms with cleaning supplies and PPE.

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, and cleaning and disinfection provisions are in adequate quantities.

LPA Mixson later discussed infection control practices and procedures with Administrator.

An exit interview was conducted and a copy of this report, along with the LIC 811, was given to Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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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