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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801279
Report Date: 09/14/2022
Date Signed: 09/14/2022 04:36:21 PM

Document Has Been Signed on 09/14/2022 04:36 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LEANING PINE, THEFACILITY NUMBER:
197801279
ADMINISTRATOR:VILLAFLOR, ELNA C.FACILITY TYPE:
740
ADDRESS:1809 LEANING PINE DRIVETELEPHONE:
(909) 396-4675
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 3DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Zenaida Uy, StaffTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the Infection Control domain. LPA was allowed entry by Staff, Zenaida Uy. Administrator, Elna Villaflor, arrived at 3:10 pm to assist with the inspection. The facility is licensed to serve five (5) non-ambulatory and one (1) bedridden residents, ages 60 and over. The bedridden fire clearance is approved for room #1 only. The facility has an approved mitigation plan.

LPA toured the facility and observed the following:
* There are 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, staff rest area, and an attached garage. There are no pools or bodies of water and no items obstructing the passageways.
* Coronavirus (COVID-19) signage are posted throughout the facility to promote hand washing hygiene, cough/sneeze etiquette, and symptom checks.
* The facility continues to screen and take the temperature of all visitors.
* Sufficient supplies of PPE are stored at the facility.
* Food supplies for 2 day perishable and a week of non-perishable are also observed.
* Knives, cleaning solutions, and disinfectants are stored and locked making them inaccessible to residents.
* Smoke detectors are connected to the security alarm system. There is one carbon monoxide detector and is operable.
* Medications are centrally stored and locked in the kitchen cabinet. LPA reviewed all 3 residents' medications and staff are administering them as prescribed.
Per the administrator, they are continuing to follow the strictest COVID-19 guidance. They clean and disinfect daily and more often for high touch surfaces.

There are no deficiencies issued today. An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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