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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800085
Report Date: 10/26/2022
Date Signed: 10/26/2022 01:45:11 PM

Document Has Been Signed on 10/26/2022 01:45 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MCCOY ADULT GROUP HOMEFACILITY NUMBER:
331800085
ADMINISTRATOR:LACY,TORIFACILITY TYPE:
735
ADDRESS:1113 GARRETSON AVETELEPHONE:
(909) 437-5262
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 6CENSUS: 3DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Shararneta Brown- Direct Care StaffTIME COMPLETED:
01:55 PM
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Licensing Program Analysts (LPAs) Victoria Chitgian and Ryan Gardner made an unannounced visit to the facility to conduct an annual inspection focused on infection control. At 12:50pm, LPAs were greeted and granted entry by Licensee Charisse McCoy and explained the purpose of the visit. At the time of visit there was (2) staff and three (3) clients present.

During today's visit, LPAs toured the facility and made observations regarding the infection control measures that the facility has implemented. The entrance of the facility has a check in process for staff and visitors that includes a temperature and symptom check. LPAs observed Covid-19 postings and proper cough etiquette postings throughout. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer). LPAs observed a thirty (30) day supply of Personal Protective Equipment (PPE) which includes gloves, face shields, gowns, disinfectant, surgical masks, N95 masks, and hand sanitizer. PPE was stored in the room near the entrance.

The facility staff has a plan in place to manage Covid-19 symptoms, which includes staff monitoring clients regularly for any changes in condition and daily temperature checks. The facility will contact the client's physician in the event of any Covid-19 related illnesses. There is a symptom screening of clients logged daily. The facility staff are responsible for cleaning and disinfecting the highly touched surface areas during their shift. All staff and clients are practicing all other Covid-19 precautions, which minimize the risk of them contracting Covid-19.

LPAs toured the facility inside and out and there were no health and safety concerns.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and a copy of this report (LIC809) was provided to Licensee Charisse McCoy.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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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