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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411948
Report Date: 01/20/2022
Date Signed: 01/20/2022 11:27:26 AM

Document Has Been Signed on 01/20/2022 11:27 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:ROSE ALLEY GUEST HOME IIFACILITY NUMBER:
366411948
ADMINISTRATOR:RADOI, ANAFACILITY TYPE:
740
ADDRESS:35655 TERIANN LANETELEPHONE:
(909) 797-5512
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 6CENSUS: 0DATE:
01/20/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Ana RadoiTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility announced in order to complete the facility's Annual Inspection. LPA Brown met with Licensee/Administrator Ana Radoi and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Licensee/Administrator Radoi. Administrator Radoi reported that Mitigation Plan was submitted last January 2021. LPA Brown requested Licensee/Administrator Radoi to send a copy of Mitigation Plan via email.

LPA Brown observed the facility to not having Covid-19 signages throughout the facility for cough etiquette, proper hand washing procedure, social distancing and requested Licensee/Administrator to post appropriate Covid-19 signages throughout the facility. Administrator Radoi reported that she removed the signages because they are renovating the facility. Currently, no residents at the facility and LPA Brown toured the facility's resident bedrooms and bathrooms and observed that both resident bathrooms have paper towels and hand soap..

LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, and face shields/goggles or isolation gowns. LPA Brown went over the various recommended training for facility staff with Licensee/Administrator Radoi in relation to COVID-19 and informed Licensee/Administrator that once they have residents, staff needs to be trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

*** continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2022
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: ROSE ALLEY GUEST HOME II
FACILITY NUMBER: 366411948
VISIT DATE: 01/20/2022
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LPA Brown informed Licensee/Administrator Radoi that once the facility will have residents, staff are required to have been fit tested for N95 masks.

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 will be trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their residents, once they have one 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 their residents 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.

Based on the observations made during today’s visit, no deficiencies were cited. An exit interview was conducted with Licensee/Administrator Ana Radoi and a copy of this report (LIC 809) was provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC809 (FAS) - (06/04)
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