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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603141
Report Date: 06/24/2022
Date Signed: 06/24/2022 01:55:11 PM

Document Has Been Signed on 06/24/2022 01:55 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:RISING HILL DEVELOPMENTAL HOMEFACILITY NUMBER:
198603141
ADMINISTRATOR:LEWIS, FELISHAFACILITY TYPE:
735
ADDRESS:1 RISING HILL RDTELEPHONE:
(909) 417-5505
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 4CENSUS: 3DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:S-1TIME COMPLETED:
02:15 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. LPAs met with S-1 and explained the purpose of the visit.

This home consists of 3 bedrooms, 2 baths, kitchen, dinning area, den/game room, living room and attached garage.

The following were observed/inspected:
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • PPE supplies observed. Additional supplies are stored inside the garage.
  • Restrooms have hand soap and paper towels.
  • Hand sanitizers observed in common areas throughout this facility.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Additional food supply is stored inside the garage.
  • Per S-1, all (3) clients have both vaccines and 1st booster.
  • Medication reviewed for (3) Clients (Client #1 through Client #3).
  • Clients social distance according to local public health guidelines.
  • Per S-1, there are (5) staff members have both vaccines and some have a pending booster.
  • Staff responsible for direct care and supervision will wear masks.

The infection control tool was sent to LPA via e-mail today (during today's visit).

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: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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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