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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426555
Report Date: 07/15/2021
Date Signed: 07/15/2021 11:48:17 AM

Document Has Been Signed on 07/15/2021 11:48 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:APPEARANCE QUALITY HOMEFACILITY NUMBER:
366426555
ADMINISTRATOR:RILEY, RACHELFACILITY TYPE:
740
ADDRESS:10752 OAKWOOD AVE.TELEPHONE:
(760) 956-2800
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 6DATE:
07/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Administrator Rachel Riley TIME COMPLETED:
10:53 AM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Caregiver Roseline Osakpolor, and explained the purpose of the visit. Administrator Rachel joined shortly after. At the time of visit there were 2 staff and 6 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer), as well as Personal Protective Equipment (PPE) supplies.

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to Rachel Riley.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2021
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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