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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005705
Report Date: 04/18/2022
Date Signed: 04/18/2022 02:50:56 PM

Document Has Been Signed on 04/18/2022 02:50 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:EDWARD BOARD AND CARE HOMEFACILITY NUMBER:
306005705
ADMINISTRATOR:HERNANDEZ, MARISAFACILITY TYPE:
735
ADDRESS:117 EDWARD AVE.TELEPHONE:
(714) 290-3809
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 4CENSUS: 4DATE:
04/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Justin RodriguezTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a required/annual inspection. LPA was greeted by staff Justin Rodriguez. LPA discussed the purpose of the inspection and was granted entry into the facility. LPA and staff Rodriguez conducted a tour of the inside and outside of the facility, common areas, kitchen, restrooms, kitchen and observed the following:

This is a single-story house with five bedrooms, and three bathrooms. During the inspection, LPA observed there was one staff present with one resident in physical care and three residents away on overnight visits with family. LPA observed no hand washing and/or cough etiquette signs, facility was also noted to have no Personal Protective Equipment (PPE); two Technical Advisories were given on this date. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

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 left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
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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