<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005633
Report Date: 07/12/2021
Date Signed: 07/27/2021 09:07:12 AM

Document Has Been Signed on 07/27/2021 09:07 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MARYKNOLL SENIOR CAREFACILITY NUMBER:
306005633
ADMINISTRATOR:UMALI, FRANCES AMANDAFACILITY TYPE:
740
ADDRESS:531 WHITTEN WAYTELEPHONE:
(805) 836-1556
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 5DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Amanda UmaliTIME COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival, LPA met with Staff Nemecio Masone, Nestor Librado and Rhoda Yturralde. . LPA explained the purpose of the visit. Administrator Amanda Umali arrived a short time later.

During the visit LPA toured the facility inside and out with Nestor Librado. LPA observed Covid signage at front entrance of facility as well as a sanitization station. Facility has required Department postings. LPA observed a copy of Amanda Umali's Administrator Certificate. The Certificate expired 2/1/21. There was an error with the check date, she is awaiting her new certificate. LPA toured all resident rooms. Rooms were clean and sanitary. Restrooms and rooms observed contained ample supplies of hand sanitizer, soap, wipes, gloves and paper towels. LPA observed outside visitation area with ample shading. There were 5 resident's present. Residents were observed resting, visiting with family and watching tv in their rooms. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA also observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted about the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA discussed sign in and screening procedures for visitors. LPA advised the importance of mask wearing and handwashing for staff and residents.

No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Amanda Umali.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1