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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800165
Report Date: 09/29/2022
Date Signed: 09/29/2022 03:47:53 PM

Document Has Been Signed on 09/29/2022 03:47 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:AUSTIN SMALL ARIZONA FAMILY HOME IIFACILITY NUMBER:
361800165
ADMINISTRATOR:AUSTIN, ALEXANDRIAFACILITY TYPE:
735
ADDRESS:17049 LA VESU ROADTELEPHONE:
(909) 823-2624
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 6CENSUS: 3DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Adeline Austin, LicenseeTIME COMPLETED:
03:49 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced annual required visit, with an emphasis on infection control. LPA met with Licensee Adeline Austin who confirmed there are three clients in care. Licensee Austin verified that there are no active Covid cases in the home.

This facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. Single entry point at the front door has a sign-in policy for entry screening. The facility continues routine COVID-19 symptom screening for clients and visitors. Consumers are regularly observed for any changes in condition. LPA Bueno did not observe staff with face covering.

LPA Bueno and Licensee Austin toured the facility inside and outside. The facility has no bodies of water. The facility has operating combination smoke and carbon monoxide alarms. Medication and sharps are kept in safe and locked cabinets. LPA observed at least two (2) days supply of perishable food items and seven (7) days supply of nonperishable food items. The client bedrooms had the required furniture and sufficient lighting.

LPA Bueno observed no health and safety concerns at the time of visit. The facility appears to be meeting operational compliance. Technical assistance (TAs) were issued to remind the facility to submit their mitigation plan to the Department and the staff of importance of being properly fitted with masks.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and a copy of this report was provided to Mrs. Adeline Austin at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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