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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603375
Report Date: 11/09/2021
Date Signed: 11/09/2021 01:38:04 PM

Document Has Been Signed on 11/09/2021 01:38 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:CASA COLINA- TRANSITIONAL LIVING CENTERFACILITY NUMBER:
198603375
ADMINISTRATOR:WOLFSON, BRIANFACILITY TYPE:
735
ADDRESS:301 MULBERRY DR.TELEPHONE:
(909) 596-7733
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 0DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Facility AdministratorTIME COMPLETED:
01:30 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 met with Administrator and explained the purpose of today's visit. This home consists of (4) private client bedrooms, (2) bathrooms, living room, kitchen and dinning area. LPA toured grounds.

Note: This home is currently vacant and has been vacant since January 2021.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, common rooms and hallways. Everyone will undergo COVID-19 screening prior to entering this facility. Per Administrator, persons coming into the facility are to present their vaccine card or a negative COVID-19 result within the last 72 hours.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed. Additional PPE supplies are stored at Casa Colina TLC.
  • Restrooms have hand soap and hand sanitizer.
  • Emergency food supply observed. There is no perishable food as this home as it has been vacant. Per Administrator, facility will have the required food supply (perishable for 2 days and non-perishable foods for 7 days) prior to a new client admission.
  • Per Administrator, when a new admission occurs at this facility, any unvaccinated Clients and/or Staff will undergo weekly COVID-19 testing.
  • Per Facility Administrator, staff responsible for direct care and supervision will wear masks.
  • Per Facility Administrator, clients will be 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: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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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