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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427409
Report Date: 08/19/2022
Date Signed: 08/19/2022 03:30:04 PM

Document Has Been Signed on 08/19/2022 03:30 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:FAMILYCARE HOME - PROSPERITYFACILITY NUMBER:
336427409
ADMINISTRATOR:KO, JOSEPH DEXTERFACILITY TYPE:
740
ADDRESS:11588 PROSPERITY LANETELEPHONE:
(951) 221-1741
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 3DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Alberto Baltazar, House ManagerTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA arrived at approximately 01:55 PM, signed in and utilized hand sanitizer. The LPA met with House Manager, Alberto Baltazar, and informed him of the purpose of the visit. There are currently no cases of COVID-19 within the facility.

During today's visit, the LPA toured the home and made observations pertaining to the facility's infection control measures. The LPA observed sufficient hand hygiene supplies and proper use of face coverings. The facility has a designated infection control lead person. The facility has a COVID-19 plan in place which is pending review from the Department. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, Chapter 1 or 6 of the California Code of Regulations. An exit interview to review this report was conducted with Baltazar and a copy of this report was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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