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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880522
Report Date: 07/27/2022
Date Signed: 07/27/2022 02:57:33 PM

Document Has Been Signed on 07/27/2022 02:57 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:JOSEPHINE'S CARE HOMEFACILITY NUMBER:
361880522
ADMINISTRATOR:PENDINGFACILITY TYPE:
735
ADDRESS:1566 E. HAZELTINETELEPHONE:
(909) 996-2108
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 4CENSUS: 4DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Administrator Dominador BartolataTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 07/27/2022 at 12:50 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrator Dominador Bartolata and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Administrator Bartolata 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 Bartolata. Per documents review, Mitigation Plan was submitted 01/13/2021. Also, Administrator Bartolata reported that the facility’s Infection Control Plan will be submitted not later than 07/31/2022.

LPA Brown observed the facility with 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 surgical masks, gloves, isolation gown, hand sanitizers, wipes but only one (1) N95 respirator mask available at the facility. LPA Brown will be issuing a Technical Advisory Note for this issue. LPA Brown went over the various recommended training for facility staff with Administrator Bartolata in relation to COVID-19 and Administrator Bartolata 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: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: JOSEPHINE'S CARE HOME
FACILITY NUMBER: 361880522
VISIT DATE: 07/27/2022
NARRATIVE
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LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Bartolata informed LPA Brown that all staff have not been fit tested for N95 masks 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 had Covid-19 positive client last 06/22/2022 and N95 masks needs to be worn when a client is COVID-19 positive or under observation while awaiting test results.

Additionally, Administrator Bartolata reported that all four (4) clients are vaccinated and boosted, and all staff are vaccinated and boosted. Moreover, LPA Brown observed 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 event of any COVID-19 related and/or suspected illnesses.

During the visit and per documents review, LPA Brown observed Staff 3 with criminal background clearance but not associated at the facility. LPA Brown will be issuing a deficiency for this issue as this pose potential risk to clients in care. Administrator James Santiago arrived during the visit and informed LPA Brown that Staff 3 is now associated at the facility as Administrator Santiago updated facility roster in Guardian.

Moreover, LPA Brown requested Staff Vaccination record at around 01:30 PM and per documents review, LPA Brown observed Staff 1, Staff 2, Staff 3, Staff 5 and Staff 6 all have dose 1, dose 2, and booster vaccination record however Staff 4 only have dose 1, dose 2 but no booster vaccination record at the facility. LPA Brown will be issuing a deficiency for this issue.

An exit interview was conducted with 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: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/27/2022 02:57 PM - It Cannot Be Edited


Created By: Melody Brown On 07/27/2022 at 02:20 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: JOSEPHINE'S CARE HOME
FACILITY NUMBER: 361880522

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Each client shall have personal rights including: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her 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 N95 respirator fit test to all the staff at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2022
Plan of Correction
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Licensee stated to provide all staff with N95 respirator fit test and submit proof to LPA Brown by POC due date.
Type B
Section Cited
CCR
80019(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

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 transferring the criminal background clearance of Staff 3 to the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Licensee trasferred the criminal background clearance of Staff 3 to the facility during the visit and proof showed to LPA Brown. Deficiency cleared..
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: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/27/2022 02:57 PM - It Cannot Be Edited


Created By: Melody Brown On 07/27/2022 at 02:30 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: JOSEPHINE'S CARE HOME
FACILITY NUMBER: 361880522

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
121125,120140,120276


This requirement is not met as evidenced by:
Deficient Practice Statement
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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 persons in care to live in a safe, healthy, 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 Licensee did not verify worker's vaccination, booster or exemption status or unvaccinated worker's test results 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
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Licensee stated to submit proof of booster vaccination/exemption of Staff 4 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: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
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