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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880936
Report Date: 10/21/2021
Date Signed: 10/21/2021 01:48:00 PM

Document Has Been Signed on 10/21/2021 01:48 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:ACTIVE BOARD AND CAREFACILITY NUMBER:
361880936
ADMINISTRATOR:RAMOS, ISABELITA DEFACILITY TYPE:
740
ADDRESS:1396 N. 1ST AVE.TELEPHONE:
(951) 818-1140
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 6DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Maria AbelardoTIME COMPLETED:
01:50 PM
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On 10/21/21 at 12:44 PM, Licensing Program Analyst (LPA) Anna Bueno arrived unannounced at the facility to conduct a required annual inspection, with an emphasis on infection control. LPA met with live in staff, Maria Abelardo, who was explained the nature of the inspection and LPA granted entry into the facility. There are currently 6 residents at the facility. Covid-19 risk assessment was conducted verbally with Abelardo and it was confirmed that there are no active and/or suspected COVID-19 cases in the facility. Administrator Isabelita De Ramos was phoned by staff and arrived shortly but left before the conclusion of today's inspection.

LPA toured the facility with the caregiver. There is a mitigation plan in place to help mitigate the spread of COVID-19 in the facility. There is one point of entry for routine COVID-19 symptoms screening is initiated for all residents, staff and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients. LPA observed hand sanitizer throughout the facility. LPA observed a sufficient supply of hand hygiene, cleaning and disinfecting items. LPA observed a sufficient supply of Personal Protective Equipment (PPE) that included surgical masks, gloves, hand sanitizer, and alcohol. The facility has a designated infection control person who is responsible for ensuring that the facility is compliance with infection control practices. The facility has a COVID mitigation plan in place, which outlines testing requirements, isolating/quarantining positive COVID-19 cases, proper cleaning, sanitizing, disinfecting, and monitoring of individuals for COVID-like symptoms.

LPA and staff toured the resident bedrooms and observed all the appropriate furnishings in place. The facility has charged fire extinguishers and operational dual smoke detector and carbon monoxide alarms

According to California Code of Regulations, Title 22, Division 6, there were no deficiencies observed or cited during this visit. An exit interview was conducted where this report was discussed with and provideed to Abelardo.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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