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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601183
Report Date: 10/06/2021
Date Signed: 10/07/2021 07:48:06 AM

Document Has Been Signed on 10/07/2021 07:48 AM - 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:ENGLISH FAMILY CARE HOME, INC.FACILITY NUMBER:
198601183
ADMINISTRATOR:BRENDA SEABORNFACILITY TYPE:
735
ADDRESS:984 RUSSELL PLACETELEPHONE:
(909) 620-1741
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 2DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Facility AdministratorTIME COMPLETED:
03:05 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 was allowed entry by Facility Administrator and explained the purpose of today's visit.


The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Each Client has their own bedroom.
  • Per Administrator all staff and clients are fully vaccinated.
  • 30 day supply of medication reviewed for (2) clients.
  • PPE supplies observed.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Clients were socially distanced according to local public health guidelines.

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: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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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