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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880525
Report Date: 10/13/2022
Date Signed: 10/13/2022 12:14:34 PM


Document Has Been Signed on 10/13/2022 12:14 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MERRILL GARDENS AT RANCHO CUCAMONGAFACILITY NUMBER:
361880525
ADMINISTRATOR:TAMO, DAVIDFACILITY TYPE:
740
ADDRESS:9942 HIGHLAND AVENUETELEPHONE:
(909) 303-9545
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91737
CAPACITY:150CENSUS: 107DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:David TamoTIME COMPLETED:
12:22 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Natalie Ibarra and Paola Guerrero made an unannounced visit to conduct an annual inspection, with emphasis on infection control. LPAs met with administrator David Tamo and explained the purpose to today's visit. Administrator accompanied LPAs on a tour of the facility.

LPAs toured the facility and made observations pertaining to the facility’s infection control measures. LPAs observed signage throughout the facility for proper cough etiquette, hand washing procedure, and/or social distancing guidelines. The residents have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. Facility has sufficient hand hygiene, cleaning, and disinfecting supplies. The staff working at the facility were all properly wearing face masks. LPAs requested to inspect the facility's Personal Protective Equipment (PPE) supply. The facility has a full thirty (30) day supply of PPEs such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer. LPAs observed one central entry point and a sign-in has been designated for screening that includes a vaccination verification/negative COVID test check, temperature check, and symptom check. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in 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 residents for COVID-19, when and how to isolate/quarantine residents, 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 residents regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

No deficiencies were cited during today’s visit
An exit interview was conducted, and a copy of this report was discussed and provided to Administrator David Tamo...
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Natalie IbarraTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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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