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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601637
Report Date: 03/04/2022
Date Signed: 03/04/2022 11:15:11 AM


Document Has Been Signed on 03/04/2022 11:15 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:ST. DANIEL'S HOME FOR THE ELDERLY II, INC.FACILITY NUMBER:
198601637
ADMINISTRATOR:DEBORAH DAVISFACILITY TYPE:
740
ADDRESS:2315 NAVARRO DRIVETELEPHONE:
(909) 624-1286
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 4DATE:
03/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:S-1/Facility AdministratorTIME COMPLETED:
11:30 AM
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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 S-1/Facility Administrator and explained the purpose of today's visit.

This home consists of (4) bedrooms, (3) bathrooms, living room, T.V. room, kitchen, dinning area, laundry room, storage room and attached garage. LPA toured grounds.

The following were observed/inspected: .
  • 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. These items are stored and easily accessible inside the hallway closet.
  • Hygiene supplies observed. These items are stored inside the storage room.
  • Water supply observed. Additional water supply observed inside the garage.
  • Hand Sanitizer observed throughout the facility grounds.
  • Restrooms have hand soap and hand sanitizer.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Per Administrator, all (4) Residents are fully vaccinated and have their booster.
  • Per Administrator, all staff are fully vaccinated and have their booster.
  • Medication reviewed for (4) Residents (Residents #1 through Residents #4).
  • Residents were be socially distanced according to local public health guidelines.
  • Staff responsible for direct care and supervision will continue to wear masks.

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-1/Facility Administrator.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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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