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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880884
Report Date: 03/30/2022
Date Signed: 04/04/2022 08:50:43 AM

Document Has Been Signed on 04/04/2022 08:50 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
, CA 92507
FACILITY NAME:AB'S HUMBLE HOME #2FACILITY NUMBER:
361880884
ADMINISTRATOR:HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:14798 CAMBRIA STTELEPHONE:
(909) 365-4265
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 6DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:House Manager Lanny LattaTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 03/30/2022 at 12:40 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with House Manager Lanny Latta and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with House Manager Lanny Latta and House Manager Latta reported that Mitigation Plan was submitted 07/12/2021. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. However, LPA Brown observed no central entry point and routine symptom screening has been designated for universal entry screening. LPA Brown requested House Manager Latta to set-up Central Entry Point and Routine Symptom Screening and LPA Brown discussed its importance to House Manager Latta. LPA Brown will be issuing a deficiency as this practice has a health and safety impact that includes but is not limited to personal rights, health related services and personnel requirements. Central Entry Point and Universal Screening has been set-up during the visit.

LPA Brown toured the facility's and observed that resident bathrooms have paper towels and hand soap. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks but no face shields/goggles and isolation gowns. LPA Brown will be issuing a Technical Assistance Advisory Note instead of a deficiency due it being difficult to access face shields and isolation gowns at numerous points during the COVID-19 pandemic. LPA Brown advised the facility to look online for items missing from their PPE supply kit, as CCL may not have these items to supply them with.

LPA Brown went over the various recommended training for facility staff with House Manager Latta in relation to COVID-19 and House Manager Latta reported that all staff were trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.


*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: AB'S HUMBLE HOME #2
FACILITY NUMBER: 361880884
VISIT DATE: 03/30/2022
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LPA Brown inquired as to if staff have been fit tested for N95 masks, and House Manager Latta informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, all residents and staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown informed House Manager Latta of the Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

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. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their residents for COVID-19, when and how to isolate/quarantine resident, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their residents regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During the visit, LPA Brown requested staff vaccination records and on 03/30/2022 at 01:15 PM, LPA Brown observed no vaccination record for all staff at the facility. House Manager Latta contacted Licensee/Administrator Ebraheem Hamed and Licensee/Administrator Ebraheem Hamed reported that he had their staff vaccination records and Licensee/Administrator Ebraheem Hamed also confirmed that no staff vaccination record available at the facility but he will email staff vaccination records to LPA Brown during the visit. LPA Brown received copies of staff vaccination records via email and requested House Manager Latta to keep a copy at the facility. Also, LPA Brown observed expired Administrator certification for Administrator Ebraheem Hamed and LPA Brown contacted Administrator Hamed and he sent current Administrator Certificate to LPA Brown via email.

An exit interview was conducted with House Manager Lanny Latta and a copy of this report (LIC809), LIC809D, LIC9102 AN Technical Assistance Advisory Notes and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/04/2022 08:50 AM - It Cannot Be Edited


Created By: Melody Brown On 03/30/2022 at 03:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: AB'S HUMBLE HOME #2
FACILITY NUMBER: 361880884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
121125,120140,120276
One central entry point has been designated for universal entry screening. This practice has a helath and safety impact that includes, but is not limited to personal rights, health-related services and personnel requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview, the licensee did not comply with the section cited above by not having one central entry point designated for universal entry screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2022
Plan of Correction
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Licensee stated to designate one central entry point for universal entry screening by POC due date.
LIcensee designate and set-up one central entry point during the visit. POC cleared.
Type B
Section Cited
HSC
121125,120140,120276

Routine symptom screening has been initiated at entry for all staff, residents, and visitors. This practice has a health and safety impact that includes but is not limited to personal rights, health related services, responsibility for providing care and supervision and personnel requirements.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having routine symptom screening initiated at central entry for all staff, residents and visitors which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2022
Plan of Correction
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Licensee stated to have a routine symptom screening initiated at entry for all staff, residents and visitors by POC due date.
Licensee initiate/set-up routine symptom screening at entry for all staff, residents and visitors during the visit. POC cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


LIC809 (FAS) - (06/04)
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