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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426434
Report Date: 06/14/2022
Date Signed: 06/14/2022 09:32:44 AM


Document Has Been Signed on 06/14/2022 09:32 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:BROOKDALE CORONAFACILITY NUMBER:
336426434
ADMINISTRATOR:MARITZA LUJANFACILITY TYPE:
740
ADDRESS:2005 KELLOGG AVETELEPHONE:
(951) 898-6991
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:60CENSUS: 47DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:12 AM
MET WITH:Maintenance Director, Joe ChavezTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Jennifer Semin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility. LPA met and toured the facility with Maintenance Director, Joe Chavez. Executive Director Brittany Martinez arrived at the end of the visit. LPA advised him of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only.

LPA went over COVID-19 best practices for infection control and prevention with Mr. Chavez and staff are successfully incorporating the facility's Mitigation Plan. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels.
LPA observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for local fire department has been updated. LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the central entry point for convenience. LPA observed a large storage unit with an abundant supply of PPE items. Gloves, face shields, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer supply and is inaccessible to residents.
LPA observed multiple boxes prepared and ready to be dedicated for isolation rooms, along with trash cans to put inside and outside isolation rooms.
LPA inquired as to if staff have been fit tested for N95 masks, and Mr. Chaves is not aware if staff have or have not been fit tested. Ms. Martinez has been fit tested and was able to confirm that staff have been fit tested.

An exit interview was conducted where this report was discussed and provided to Ms. Martinez.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
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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