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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360910971
Report Date: 05/11/2022
Date Signed: 05/11/2022 02:20:50 PM

Document Has Been Signed on 05/11/2022 02:20 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:PLEASANT BOARD AND CAREFACILITY NUMBER:
360910971
ADMINISTRATOR:LIGAYA P. DE JESUSFACILITY TYPE:
735
ADDRESS:1559 SO. PLEASANT AVE.TELEPHONE:
(909) 984-8594
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 6CENSUS: 4DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Harold de JesusTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 05/11/2022 at 12:45 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrator Harold de Jesus and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator de Jesus. Per documents review, Mitigation Plan was submitted 01/03/2021.

LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility's client bedrooms and bathrooms and observed that both client 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 PPE. LPA Brown went over the various recommended training for facility staff with Administrator de Jesus in relation to COVID-19 and Administrator de Jesus informed LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator de Jesus informed LPA Brown that no staff had been fit tested at this time. LPA Brown will be issuing a deficiency during today's inspection for staff not being fit tested for N95 masks due to the facility having COVID-19 positive client last 12/29/2021, and N95 masks needs to be worn when a client is COVID-19 positive or under observation while awaiting test results.
**** Continuation in LIC809C ****
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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: PLEASANT BOARD AND CARE
FACILITY NUMBER: 360910971
VISIT DATE: 05/11/2022
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Additionally, Administrator de Jesus reported to LPA Brown that all clients and staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown will be providing Administrator de Jesus with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

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 05/11/2022 at 01:15 PM, LPA Brown observed all staff are vaccinated and boosted and there’s a staff vaccination record maintained at the facility.

An exit interview was conducted with Administrator Harold de Jesus and a copy of this report (LIC809), LIC 809D and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/11/2022 02:20 PM - It Cannot Be Edited


Created By: Melody Brown On 05/11/2022 at 02:06 PM
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: PLEASANT BOARD AND CARE
FACILITY NUMBER: 360910971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80078(a)
Responsibility for Providing Care and Supervision
(a)The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not providing all staff who are working with Covid-19 positive clients with fit testing for N95 respirators which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2022
Plan of Correction
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Licensee stated to have all staff N95 Fit Tested and submit proof to LPA Brown by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022


LIC809 (FAS) - (06/04)
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