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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603167
Report Date: 01/28/2022
Date Signed: 01/28/2022 11:46:56 AM

Document Has Been Signed on 01/28/2022 11:46 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:SEMORA ARF INCFACILITY NUMBER:
198603167
ADMINISTRATOR:MACHADO, MARY LFACILITY TYPE:
735
ADDRESS:10609 SEMORA STTELEPHONE:
(714) 676-7005
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 4CENSUS: 4DATE:
01/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Norlan MachadoTIME COMPLETED:
12:00 PM
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1/28/2022 Licensing Program Analyst (LPA) Nina Galarza and Department of Health (DPH) Nurse, Lynn Nottingham conducted a case management visit to address the COVID out break at the facility. Currently, there are no COVID positive clients or staff. LPA and DPH Nurse met with Administrator, Norlan Machado and stated the purpose of the visit.

LPA, Administrator and DPH Nurse toured the facility. Upon arriving at the facility, COVID informational and visitor policy were observed. DPH Nurse discussed entrance protocol, to ensure there is symptom screening completed for all visitors. Importance of Hand Hygiene was discussed. DPH Nurse discussed visitor long and its importance to document all visitors to possibly track how and when an outbreak took place. DPH Nurse discussed staggered meal times, Administrator confirmed that clients eat at staggered meal times. Proper sanitization of bathrooms was discussed.

Below are LA County Department of Public Health recommendations:
  • Remove living room chair as needed in order to foster social distance practices.

  • Remove patio chairs as needed in order to foster social distance practices.

  • Remind families that are visiting clients outside of the facility to wear a mask and to practice social distancing.

  • Sanitize high traffic common areas be disinfected at least 3 times a day.

  • For future possible outbreaks, use color code system, Red-Quarantine, Yellow-Isolation, Green- cleared.
CONTINUED 809-C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SEMORA ARF INC
FACILITY NUMBER: 198603167
VISIT DATE: 01/28/2022
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DPH Nurse discussed the importance of completing and submitting a line list. DPH Nurse initially sent line list, Community Care Facilities (CCF) guidance, Health Officer Order and Outbreak Notification Letter to Administrator on 1/21/2022. DPH requested line list to be completed and submitted by 1/25/2022. DPH Nurse sent line list for the third time on 1/27/2022. Administrator has not completed nor submitted a line list as of today 1/28/2022.

The facility was provided additional recommendations by DPH via email.

Exit Interview conducted, a copy of this report provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
LIC809 (FAS) - (06/04)
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