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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427577
Report Date: 10/31/2022
Date Signed: 10/31/2022 12:28:31 PM

Document Has Been Signed on 10/31/2022 12:28 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:CANYON LAKE TERRACEFACILITY NUMBER:
336427577
ADMINISTRATOR:JULITA MENDOZAFACILITY TYPE:
740
ADDRESS:30701 EMPEROR DRIVETELEPHONE:
(951) 244-1958
CITY:CANYON LAKESTATE: CAZIP CODE:
92587
CAPACITY: 6CENSUS: 6DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Administrator, Julita MendozaTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit on 10/31/2022 at 10:57 a.m. in order to conduct an annual visit with a focus on infection control. LPA met with administrator Julita Mendoza, who was informed of the purpose of the visit. At the time of the visit there were (3) staff and (6) 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. LPA observed COVID-19 postings throughout the facility. The facility has a 30-day supply of PPE equipment that is readily accessible for residents and 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. LPA will document a technical advisory note for this.

LPA reviewed the staff roster and check the Guardian roster for staff background checks. LPA observed all staff have a cleared background. LPA reviewed the LIC9020 and observed all PCP and responsible party information have been updated. LPA also reviewed the administrator's certificate and confirmed that (2) staff have a current administrator's certificate.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where this report was reviewed and provided to administrator Julita Mendoza
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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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