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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001086
Report Date: 02/15/2023
Date Signed: 02/15/2023 02:02:44 PM

Document Has Been Signed on 02/15/2023 02:02 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:DOWNIE HOMEFACILITY NUMBER:
306001086
ADMINISTRATOR:PLACIDA DELA CRUZFACILITY TYPE:
735
ADDRESS:12832 DOWNIE PLACETELEPHONE:
(714) 539-6601
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 6CENSUS: 6DATE:
02/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Rufina Devera, Victor CapadaTIME COMPLETED:
02:15 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Staff #1 (S1) Rufina Devera and discussed the purpose of the inspection. Staff #2 (S2) Victor Capada arrived during the inspection. Administrator (AD) Placida Dela Cruz appeared via telephone. During the inspection, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following:

During the inspection, LPA observed there were 3 staff present, wearing PPE. LPA observed 2 residents were present. LPA confirmed all residents were doing well and observed no health and safety issues. LPA inspected common areas, resident rooms, kitchen, and garage and observed they were clean and organized, and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, and communication and emergency plan. LPA requested and reviewed the resident roster, staff roster, resident files, staff files, the COVID-19 Mitigation Plan, and Emergency Disaster Plan. LPA provided technical assistance regarding Infection Control Plan, N95 Fit Testing, and Guardian. Please review Provider Information Notice (PIN) 22-18-ASC, as well as related PINs, and submit the Infection Control Plan immediately if you have not already done so.
There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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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