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. LPA toured the facility grounds.This home consists of (4) bedrooms, 2 full-bathrooms, kitchen, dinning area, living room, laundry room, office and an attached garage. There are (4) clients residing at this home. All clients receive case management services provided by San Gabriel Pomona Regional Center. (2) out of (4) clients are over the age of 59. LPA provided Facility Administrator with Title 22, Section 85068.4 Acceptance and Retention Limitations regulations for future reference.

COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, in all common rooms and hallways.

Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing.

All Clients have their own private bedroom.

Medication reviewed for (4) Clients (Client #1 through Client #4).

Per Administrator, all (4) clients are fully vaccinated. COVID Booster remains pending.

Per Administrator, all staff are fully vaccinated. Approximately, (9) staff COVID Booster remains pending.

PPE supplies observed. They are stored inside a hallway closet and inside the garage. Hygiene supplies are stored inside the laundry room and garage. All common areas and client bedrooms have a hand sanitizers.

Staff responsible for direct care and supervision were observed wearing masks.

Clients were socially distanced according to local public health guidelines.

Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Facility Administrator. Note: LPA was experiencing technical difficulties during this visit.