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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426756
Report Date: 09/17/2021
Date Signed: 09/17/2021 04:14:03 PM

Document Has Been Signed on 09/17/2021 04:14 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:CARING TEAM HOME CAREFACILITY NUMBER:
366426756
ADMINISTRATOR:CLEMONS, NORAFACILITY TYPE:
740
ADDRESS:9736 11TH AVE.TELEPHONE:
(760) 998-2108
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 5DATE:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Nora ClemonsTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Stephanie Williams conducted 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. LPA Williams arrived and met with Administrator, Nora Clemons. Clemons confirmed that there are currently no cases/exposures of COVID-19 within the facility. LPA Williams was screened for COVID-19 symptoms and asked to sign-in upon arrival.

During the inspection, LPA Williams conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA Williams observed appropriate postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA Williams observed that the facility staff were wearing face coverings. 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 facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents 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 resident presents any COVID-19 symptoms.

LPA Williams observed no apparent health and safety concerns at the time of visit. An exit interview was conducted where this report was discussed and a copy of this report was provided to Clemons at the conclusion of the inspection.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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