360910197-7-26-2022-56-AS-MBRN-CGPNUS-20220726104650

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360910197
Report Date: 07/26/2022
Date Signed: 07/26/2022 10:47:08 AM

Document Has Been Signed on 07/26/2022 10:47 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:	MYERS HOME		FACILITY NUMBER:	360910197
ADMINISTRATOR:	MYERS, CINDY		FACILITY TYPE:	735
ADDRESS:	4799 GRAND AVE.		TELEPHONE:	(909) 628-4866
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91762
CAPACITY: 4		CENSUS: 2	DATE:	07/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	LIcensee/Administrator Cindy Myers		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Melody Brown arrived at the facility 07/26/2022 at 09:00 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Licensee/Administrator Cindy Myers and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Licensee/Administrator Myers reported that they have two (2) clients at the facility. Below is a summary of what was observed: Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Licensee/Administrator Myers. Per documents review, Mitigation Plan was submitted 01/9/2021. Also, Licensee/Administrator Myers reported that she’s still working on the facility’s Infection Control Plan and will submit the Infection Control Plan not later than 07/31/2022. LPA Brown observed the facility with limited Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. Signs have been posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect clients from infection during pandemic. LPA Brown toured the facility, and all rooms and bathrooms have hand soap and paper towels. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of N95 masks, surgical masks, gloves, isolation gown, hand sanitizers, wipes but only one (1) goggles available at the facility. LPA Brown will be issuing a Technical Advisory Notes during today’s visit for not having sufficient number of face shield/goggles at the facility. LPA Brown went over the various recommended training for facility staff with Licensee/Administrator Myers in relation to COVID-19 and Licensee/Administrator Myers reported to LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. ** Continuation in LIC809C **

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MYERS HOME	FACILITY NUMBER: 360910197
	VISIT DATE: 07/26/2022

NARRATIVE

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LPA Brown inquired as to if staff have been fit tested for N95 masks, and Licensee/Administrator Myers informed LPA Brown that staff have not been fit tested for N95 masks at this time. LPA Brown will be issuing a Technical Advisory Note during today's inspection for staff not being fit tested for N95 masks due to the facility not having Covid-19 positive clients and staff, and N95 masks needs to be worn when a client is COVID-19 positive or under observation while awaiting test results.

Additionally, LPA Brown observed all clients and most staff have been vaccinated and most are boosted, and all staff and clients are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

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 and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their clients regularly for any changes in condition and to subsequently notify the clients physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During the visit, LPA Brown requested staff vaccination records and on 07/26/2022 at 09:45 AM, LPA Brown observed Staff 1 and Staff 2 both have dose 1, dose 2 and booster vaccination record at the facility and Staff 3 only have dose 1, dose 2 but no booster vaccination/exemption record at the facility.. LPA Brown will be issuing a deficiency for this issue as this pose potential risk to clients in care.

An exit interview was conducted with Licensee/Administrator Cindy Myers and a copy of this report (LIC809), LIC 809D, LIC9102 TA Advisory Note and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/26/2022 10:47 AM - It Cannot Be Edited

Created By: Melody Brown On 07/26/2022 at 10:26 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MYERS HOME	FACILITY NUMBER: 360910197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

121125,120140,120276

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring the personal rights of person in care to live in a safe, comfortable home failed to comply with reporting and personnel requirements and engaged in conduct inimical to the health, welfare and safety of persons in care in that the licensee did not verify , workers vaccination, booster or exemption status or uinvaccinated worker's test result as applicable by maintaining a record as required by State Public Officer Order of December 22, 2021 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2022
	Plan of Correction
1 2 3 4	Licensee stated to submit proof of Staff 3 (S3) booster vaccination/exemption to LPA Brown by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Efren Malagon

LICENSING EVALUATOR NAME:

Melody Brown

LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC809 (FAS) - (06/04)

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