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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601885
Report Date: 08/15/2022
Date Signed: 08/15/2022 11:02:09 AM

Document Has Been Signed on 08/15/2022 11:02 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:GRAYBURN HOMEFACILITY NUMBER:
198601885
ADMINISTRATOR:ELAINE MILLERFACILITY TYPE:
735
ADDRESS:2973 GRAYBURN STTELEPHONE:
(909) 596-5360
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 3DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:S-1TIME COMPLETED:
11:00 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 and explained the purpose of today's visit.

This is a single home with (4) bedrooms, (2) bathroom, living room, kitchen, dinning area and an attached garage.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices were observed at the entrance of this facility and throughout the facility.
  • COVID signs were throughout the facility.
  • Bathrooms had hand soap, paper towels and hand sanitizer. Hand washing signs observed inside the bathrooms as well.
  • PPE and hygiene supplies observed. Additional supplies are stored inside the garage.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Staff responsible for direct care and supervision were wearing masks.
  • Clients were socially distanced according to local public health guidelines.
  • Medication reviewed for (3) Clients (Client #1 through Client #3).
  • Each client has their private bedroom.
  • Per S-1, (3) clients have both COVID vaccines.
  • Per S-1, (3) staff have both COVID vaccines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-1.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2022
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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