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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609653
Report Date: 08/26/2022
Date Signed: 08/26/2022 01:15:13 PM

Document Has Been Signed on 08/26/2022 01:15 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HERNAEZ RESIDENTIAL CARE FACILITYFACILITY NUMBER:
197609653
ADMINISTRATOR:OSIO, JONAH REY G.FACILITY TYPE:
735
ADDRESS:11414 KELOWNA STTELEPHONE:
(747) 227-3450
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 6CENSUS: 5DATE:
08/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Dilia Dimayuga & Leilani OsioTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an unannounced infection control inspection/visit. Upon entry, LPA was greeted by staff Dilia Dimayuga and Leilani Osio, who allowed LPA to enter. There have not been any active or past COVID cases at the facility, and (2) staff and (5) clients are vaccinated and received booster shots. The current census is (5). LPA’s temperature was taken and documented. LPA observed staff to have full mask covering; a hand sanitizing station; PPE supplies in drawer; and COVID-19, CDC, Department of Public Health, and Licensing postings on the walls throughout the facility.

The infection control inspection began with the staff Leilani. The facility has (5) bedrooms; with (3) shared room and beds were kept (6) feet apart; with (2) staff rooms. All bedrooms were properly furnished. The common areas were observed to be clean, including bathrooms, with soap and towels. LPA conducted a mitigation plan review with the staff Leilani, to obtain information on how the facility has implemented the plan. The facility has ceased COVID testing. All new employee hires and new resident admits, must be properly screened, and vaccinated. Administration continues to conduct training to staff in relation to COVID-19. Administrator reported the facility receives departmental emails. And all clients temperature is taken daily and documented.

There are designated rooms for potential positive COVID clients. PPE, chemicals, cleaning supplies, emergency food and water, personal hygiene supplies, and paper products are stored in a locked closet.

Currently, the facility has sufficient staff, and has back-up staff in place if needed. The facility has not had any positive COVID-19 reports for staff or clients.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HERNAEZ RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197609653
VISIT DATE: 08/26/2022
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The Administrator informed LPA that they continue to implement the best practices for their facility, which has kept them COVID-19 free. The facility is aware to report any changes with clients and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview was conducted with staff Leilani.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC809 (FAS) - (06/04)
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