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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366410678
Report Date: 02/17/2022
Date Signed: 02/17/2022 03:13:09 PM

Document Has Been Signed on 02/17/2022 03:13 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 HILLS CARE HOMEFACILITY NUMBER:
366410678
ADMINISTRATOR:MELJORIE CASTELOFACILITY TYPE:
740
ADDRESS:7791 STEWART ROADTELEPHONE:
(909) 433-0612
CITY:COLTONSTATE: CAZIP CODE:
92324
CAPACITY: 6CENSUS: 5DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Meljorie CasteloTIME COMPLETED:
03:18 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Anna Bueno and Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPAs met with staff who confirmed that there are currently no cases/exposures of COVID-19 within the facility. Staff phoned Licensee who arrived during today's visit. LPAs were not screened upon entry into the facility nor asked to use hand sanitizer/hand wash.

During the inspection, LPAs conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 30+ day supply of Personal Protective Equipment (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, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the client presents any COVID-19 symptoms.

LPAs observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the

***********************CONTINUED ON LIC 809-C***********************
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HILLS CARE HOME
FACILITY NUMBER: 366410678
VISIT DATE: 02/17/2022
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California Code or Regulations. Technical advisories (TA) were provided for proper visitor screenings ensuring staff are always properly fitted with face coverings. An exit interview was conducted where this report and LIC 9102 (TA) were discussed and a copy of this report was also provided to Licensee at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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