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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880562
Report Date: 01/31/2022
Date Signed: 01/31/2022 06:03:00 PM

Document Has Been Signed on 01/31/2022 06:03 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
RIVERSIDE, CA 92507
FACILITY NAME:JEV'S PLACEFACILITY NUMBER:
361880562
ADMINISTRATOR:BERUMEN, MONICA MICHELEFACILITY TYPE:
735
ADDRESS:8345 DURANGO AVETELEPHONE:
(909) 427-0904
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 4CENSUS: 4DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Administrator Monica BerumenTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility 01/31/2022 at 04:15 PM to conduct an annual inspection, with emphasis on infection control. LPA was greeted and granted entrance by caregiver Linda de Leon and LPA explained the purpose of today's visit. Administrator Monica Berumen was contacted and arrived at the facility at around 05:45 PM. Caregiver De Leon accompanied LPA Brown on a tour of the inside and outside of the facility.

During today’s visit, LPA Brown made observation pertaining to the facility’s current infection control measures. LPA Brown observed a screening area, proper signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). 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 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 clients for COVID-19, when and how to isolate/quarantine client, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor client 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.

LPA Brown reviewed the facility’s Covid-19 training for facility staff and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. Additionally, per file review, and interview, all residents and staff are vaccinated, and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown asked Administrator Berumen via telephone at around 05:10 PM as to if staff have been fit tested for N95 masks, and Administrator Berumen informed LPA Brown that at this time staff have not been fit tested.

*** Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
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 3
Document Has Been Signed on 01/31/2022 06:03 PM - It Cannot Be Edited


Created By: Melody Brown On 01/31/2022 at 05:39 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
RIVERSIDE, CA 92507

FACILITY NAME: JEV'S PLACE
FACILITY NUMBER: 361880562

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
130
Licensee has provided all staff who are working with Covid-19 positive residents with fit testing for N95 respirators. This practice has a health and safety impact that includes, but is not limited to personal rights, buildings and grounds, and responsibility for providing care and supervision.

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 with fit testing for N95 respiratorsi which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2022
Plan of Correction
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Licensee will submit proof that all staff were provided N95 respirators fit test by POC due date to LPA Brown.
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: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022


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
RIVERSIDE, CA 92507
FACILITY NAME: JEV'S PLACE
FACILITY NUMBER: 361880562
VISIT DATE: 01/31/2022
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. LPA Brown will be issuing a deficiency during today's inspection for staff not being fit tested for N95 masks and the facility just had a COVID-19 positive staff. LPA Brown will be providing the facility with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

An exit interview was conducted with Administrator Monica Berumen and a copy of this report (LIC809), LIC809D and Appeal Rights were provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
LIC809 (FAS) - (06/04)
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