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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880589
Report Date: 07/20/2022
Date Signed: 07/20/2022 03:05:53 PM


Document Has Been Signed on 07/20/2022 03:05 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:SANDALWOOD MANORFACILITY NUMBER:
361880589
ADMINISTRATOR:DILLARD, JACQUELINEFACILITY TYPE:
740
ADDRESS:7602 PURPLE SAGE CIRTELEPHONE:
(909) 600-7028
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:4CENSUS: 3DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee/Administrator Jacqueline DillardTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 07/20/2022 at 01:00 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Licensee/Administrator Jacqueline Dillard and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Licensee/Administrator Dillard reported that they have three (3) residents 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 Licensee/Administrator Dillard. Per documents review, Mitigation Plan was submitted 07/30/2021.

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 residents 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. LPA Brown went over the various recommended training for facility staff with Licensee/Administrator Dillard in relation to COVID-19 and Licensee/Administrator Dillard 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 Licensee/Administrator Dillard informed LPA Brown that all staff have not been fit tested at this time. LPA Brown will be issuing a Technical Advisory Notes and not a deficiency during today's inspection for staff not being fit tested for N95 masks due to the facility not having Covid-19 positive residents or staff and N95 masks only needs to be worn when a resident is COVID-19 positive or under observation while awaiting test results.

**** Continuation in LIC809C ****

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
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)
Page: 1 of 4


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: SANDALWOOD MANOR
FACILITY NUMBER: 361880589
VISIT DATE: 07/20/2022
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Additionally, LPA Brown observed all residents and all staff have been vaccinated and all are boosted, and all staff and residents are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown will be providing Licensee/Administrator Dillard 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 residents, 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 their residents regularly for any changes in condition and to subsequently notify the residents 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 02:00 PM, LPA Brown observed all staff have dose 1, dose 2 and booster vaccination. In addition, during the tour of the facility, LPA Brown did not observe posting of Name, Address and Telephone Number of each emergency agency that needs to be called in the event of an emergency, including but not limited to fire department, crisis center, paramedical unit or medical resource located visible to both staff and residents. Moreover, the Name and telephone number of an ambulance service was not observe posted as well in a visible location. LPA Brown will be issuing a deficiency during this visit as this poses immediate risk to residents in care.

An exit interview was conducted with Licensee/Administrator Jacqueline Dillard and a copy of this report (LIC809), LIC 809D, LIC9102 TA Advisory Note and Appeal Rights were discussed and provided.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
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)
Page: 2 of 4
Document Has Been Signed on 07/20/2022 03:05 PM - It Cannot Be Edited

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: SANDALWOOD MANOR
FACILITY NUMBER: 361880589

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(f)(2)
Incidental Medical and Dental Care Services
(f) Emergency care requirements shall include the following: (2) The name, address and telephone number of each emergency agency to be called in the event of an emergency, including but not limited to the fire department, crisis center or paramedical unit or medical resource, shall be posted in a location visible to both staff and residents.

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 posting the name, address and telephone number of emergency agency in a visible area to both staff and residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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LIcensee stated to post the name, address and telephone number of emergency agency in a visible area to both staff and residents and submit proof to LPA Brown by POC due date.
Licensee stated to submit Statement of Understanding on CCR 87465(f)(2) to LPA Brown by POC due date.
Type A
Section Cited
CCR
87465(f)(3)
Incidental Medical and Dental Care Services
(f) Emergency care requirements shall include the following: (3) The name and telephone number of an ambulance service shall be readily available.

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 posting the name and telephone of an ambulance service and making it readilly available to both staff and residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Licensee stated to post the name and telephone number of an ambulance service and make it availble to both staff and residents and submit proof to LPA Brown by POC due date.
Licensee stated to submit Statement of Understanding on CCR 87465(f)(3) to LPA Brown by POC due date.

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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
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)
Page: 3 of 4