Facility Evaluation Report

Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Facility Administrator and explained the purpose of today's visit.

This home consists of (3) bedrooms, (2) bathrooms, living room, kitchen, dinning area, laundry room (inside the garage) and attached garage. All Clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center. There are (5) clients residing at this home. (3) out of (5) clients are over the age of 59. LPA provided Facility Administrator with Title 22, Section 85068.4 Acceptance and Retention Limitations regulations. Facility Administrator to submit required documentation to CCLD for review/processing.

COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility. Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.

PPE supplies observed. Additional PPE supplies are stored inside the hallway closet and garage.

Hygiene and incontinence supplies observed. These items are stored the hallway closet and the garage.

Restrooms have hand soap, hand sanitizer and paper towels. Hand sanitizer observed throughout the facility.

Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. An additional fully stocked refrigerator is located inside the garage.

Per Administrator, (5) clients and staff are fully vaccinated including the Booster.

Medication reviewed for (5) Clients (Client #1 through Client #5).

Staff responsible for direct care and supervision will wear masks.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Facility Administrator.