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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800111
Report Date: 07/20/2022
Date Signed: 07/20/2022 11:23:33 AM

Document Has Been Signed on 07/20/2022 11:23 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:LAS PALMAS ADULT RESIDENCEFACILITY NUMBER:
361800111
ADMINISTRATOR:UMALI, TERESITAFACILITY TYPE:
735
ADDRESS:7217 LAS PALMAS DRIVETELEPHONE:
(909) 463-4028
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 4DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Neil ConsueloTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 07/20/2022 at 09:30 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with staff Danilo Millan and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Administrator Neil Consuelo was contacted and arrived during the visit. Administrator Consuelo reported that they have four (4) 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 Administrator Consuelo. Per documents review, Mitigation Plan was submitted 05/11/2021.

LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing, and 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 PPE except for face shields. LPA Brown will be issuing Technical Advisory Notes for only having one (1) face shield available at the facility. LPA Brown went over the various recommended training for facility staff with Administrator Consuelo in relation to COVID-19 and Administrator Consuelo 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.

LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Consuelo informed LPA Brown that all staff have not 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 recently have two (2) Covid-19 positive clients and one (1) Covid-19 positive staff last 05/20/2022, 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: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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Document Has Been Signed on 07/20/2022 11:23 AM - It Cannot Be Edited


Created By: Melody Brown On 07/20/2022 at 10:50 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: LAS PALMAS ADULT RESIDENCE
FACILITY NUMBER: 361800111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(g)
Personnel Requirements
(g) All personnel, including the licensee, administrator and volunteers, shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks.

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 N95 respirator fit test to all the staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2022
Plan of Correction
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Licensee stated to have all staff N95 respirator fit test and submit proof of completed N95 respirator fit test 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: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022


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: LAS PALMAS ADULT RESIDENCE
FACILITY NUMBER: 361800111
VISIT DATE: 07/20/2022
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Additionally, LPA Brown observed all clients and all staff have been vaccinated and all are boosted, and all staff and clients are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown will be providing Administrator Consuelo 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 07/20/2022 at 10:20 AM, LPA Brown observed all staff have dose 1, dose 2 and booster vaccination.

An exit interview was conducted with Administrator Neil Consuelo 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: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC809 (FAS) - (06/04)
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