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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800219
Report Date: 10/25/2022
Date Signed: 10/25/2022 02:07:20 PM

Document Has Been Signed on 10/25/2022 02:07 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:AUSTIN SMALL ARIZONA FAMILY HOMEFACILITY NUMBER:
331800219
ADMINISTRATOR:AUSTIN, ADELINEFACILITY TYPE:
735
ADDRESS:867 MONTAGUE DRTELEPHONE:
(951) 272-9651
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 6CENSUS: 5DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Alexandria AustinTIME COMPLETED:
02:16 PM
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Licensing Program Analyst’s (LPA’s) Paola Guerrero and Ryan Gardner made an unannounced visit to the facility. The purpose of today's visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA met with Administrator Alexandria Austin.

LPA’s Guerrero and Gardner toured the facility and went over COVID-19 best practices for infection control and prevention with the Administrator. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients and properly caring for clients with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The entrance of the facility has a check in process for visitors that includes a temperature and symptom check. The clients have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. The facility has postings throughout for proper cough etiquette, proper hand washing procedure, and/or social distancing guidelines. LPAs requested to inspect the facility's Personal Protective Equipment (PPE) supply. The facility has adequate amount of PPE supplies. LPA observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, the facility is meeting operational requirements.

During today’s visit, there was a plumber at the facility fixing a water leak in the upstairs bathroom and replacing a toilet in the downstairs bathroom. Administrator stated that a special incident report (SIR), will be submitted to licensing.

No cited deficiencies per Title 22, Division 6 of the California Code of Regulations cited at this time.

An exit interview was conducted, and a copy of this report was discussed and provided to Administrator Alexandria Austin.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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