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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592503
Report Date: 11/09/2021
Date Signed: 11/09/2021 01:39:24 PM

Document Has Been Signed on 11/09/2021 01:39 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CASA COLINA TRANSITIONAL LIVING CENTERFACILITY NUMBER:
191592503
ADMINISTRATOR:BRIAN WOLFSONFACILITY TYPE:
735
ADDRESS:250 E. HARRISONTELEPHONE:
(909) 596-7733
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 42CENSUS: 39DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator and explained the purpose of today's visit. This home consists of (1) lobby, (21) shared bedrooms, (10) bathrooms, kitchen, dinning room, Residential Tech Station, Med Tech Station, Activity Room and Computer/TV Room. LPA toured grounds.

The following were observed/inspected:
  • Per Administrator, the main entrance screening during business is in building #8. For after hours and on weekends, the main entrance screening is in building #6. Per Administrator, persons coming into the facility are to present their vaccine card or a negative COVID-19 result within the last 72 hours.
  • 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 were observed.
  • Medication reviewed for (5) Clients (Client #1 through Client #5).
  • Per Administrator, approximately (5) clients are not COVID-19 vaccinated and approximately (10) to (12) staff out of approximately (64) staff are not vaccinated. Both unvaccinated Clients and Staff are undergoing and will continue to undergo weekly COVID-19 testing.
  • PPE supplies observed.
  • All common areas including entrances and client bedrooms have a hand sanitizer stations.
  • Masks, hand sanitizer and glove stations were observed at the entrances.
  • All restrooms have a station which consists of sanitizing wipes, gloves and sanitizer.
  • 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
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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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