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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426141
Report Date: 11/09/2021
Date Signed: 02/27/2023 04:37:26 PM

Document Has Been Signed on 02/27/2023 04:37 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HALCYON PLACE IFACILITY NUMBER:
366426141
ADMINISTRATOR:MARYA ALPERTFACILITY TYPE:
740
ADDRESS:6947 KIRKWOOD AVENUETELEPHONE:
(951) 818-6667
CITY:ALTA LOMASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 6DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Eva Tancinco, caregiverTIME COMPLETED:
02:20 PM
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On 11/9/21 Licensing Program Analyst (LPA) Shaunte Henry arrived at the facility to conduct an unannounced annual inspection with an emphasis on infection control. The LPA met with Eva Tancinco, explained the nature of the inspection and was granted entry into the facility. Licensee Arya Alpert was on the phone during the visit. There are currently 6 residents living in the facility. As of this date, there are no positive COVID-19 cases or individuals with COVID-19 symptoms present in the facility.

The LPA toured the facility. There is one point of entry for routine COVID-19 symptoms screening is initiated for all residents, staff and visitors. Signs have been posted throughout the facility which indicates the visitor policy and proper hand washing, cough/sneeze etiquette, and social distancing practices. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients. The LPA observed hand sanitizer throughout the facility. The LPA observed a sufficient supply of hand hygiene, cleaning and disinfecting items. The LPA observed a sufficient supply of Personal Protective Equipment (PPE) that included surgical masks, N-95 masks, face shields, gloves, gowns, glasses, etc. The facility has a designated infection control person who is responsible for ensuring that the facility is compliance with infection control practices. The facility has a COVID-19 mitigation plan in place, which outlines testing requirements, isolating/quarantining positive COVID-19 cases, proper cleaning/sanitizing/disinfecting and monitoring of individuals for COVID-19 like symptoms. The facility is aware that it is mandatory that Community Care Licensing (CCL) is contacted if anyone tests positive for COVID-19. According to California Code of Regulations, Title 22, Division 6, there were no deficiencies observed or cited during this visit. An exit interview was conducted where this report was discussed with and provided to Eva Tancinco.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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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