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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360908446
Report Date: 12/29/2022
Date Signed: 12/29/2022 10:07:07 AM

Document Has Been Signed on 12/29/2022 10:07 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JACE GUEST HOMEFACILITY NUMBER:
360908446
ADMINISTRATOR:YAN, CECILEFACILITY TYPE:
740
ADDRESS:11393 YORBA STREETTELEPHONE:
(909) 628-8640
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 15CENSUS: 6DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Licensee Cecile YanTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit to conduct an annual inspection focused on infection control. LPA met with Licensee Cecile Yan and explained the purpose of the visit. At the time of visit there were three (3) staff and six (6) resident present.

LPA 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. LPA observed postings for handwashing and proper cough etiquette throughout. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towels). LPA observed a thirty (30) day supply of Personal Protective Equipment (PPE) which includes gloves, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer. PPE was stored in a hallway closet.

The facility has a plan in place which follows Community Care Licensing Division guidelines for testing, isolating and caring for residents with COVID-19 positive results and/or exposures. There is a designated infection control lead person tasked with tracking all COVID-19 cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in effect, and that staff are trained in the proper use and disposal of PPE. The facility staff monitors residents regularly for any changes in condition and daily symptom checks. The staff will contact the resident's physician in the event of any Covid-19 related illnesses. The staff are responsible for cleaning and disinfecting the highly touched surface areas during their shift. All staff and residents are practicing all other infection control precautions, which minimize the risk of them contracting Covid-19.

LPA toured the facilities interior and exterior 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 Cecile Yan.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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