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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880704
Report Date: 05/18/2022
Date Signed: 05/18/2022 02:11:29 PM

Document Has Been Signed on 05/18/2022 02:11 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:SULE'S LOVING HOMEFACILITY NUMBER:
361880704
ADMINISTRATOR:PARRA, SULEMA EFACILITY TYPE:
735
ADDRESS:7640 TOKAY AVETELEPHONE:
(909) 329-9740
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 2DATE:
05/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator/Licensee Sulema ParraTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 05/18/2022 at 01:15 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Licensee/Administrator Sulema Parra and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. 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 Parra. Per documents review, Mitigation Plan was submitted 06/03/2021.

LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility's client bedrooms and bathrooms and observed that both client 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, however, LPA Brown observed no face shields or goggles available at the facility. LPA Brown will be issuing a Technical Assistance Advisory Note instead of a deficiency due to it being difficult to access face shields at numerous points during the COVID-19 pandemic. LPA Brown advised the facility to look online for items missing from their PPE supply kit, as Community Care Licensing (CCL) and Inland Regional Center (IRC) may not have these items to supply them with. LPA Brown went over the various recommended training for facility staff with LIcensee/Administrator Parra in relation to COVID-19 and Licensee/Administrator Parra informed 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 Administrator Parra informed LPA Brown that all staff have not been fit tested at this time. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive clients, and **** Continuation in LIC809C ****
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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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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: SULE'S LOVING HOME
FACILITY NUMBER: 361880704
VISIT DATE: 05/18/2022
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N95 masks only needing to be worn when a client is COVID-19 positive or under observation while awaiting test results. Additionally, all clients have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown will be providing Licensee/Administrator Parra 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 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 changes in condition and to subsequently notify the clients 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 05/18/2022 at 01:00 PM, LPA Brown observed only Staff 1 (S1), Staff 2 (S2), Staff 3 (S3) and Staff 5 (5) have Dose 1 and Dose 2 vaccination record and only Staff 1 have Booster Vaccination Record and Staff 2 (S2), Staff 3 (S3), Staff 5 have no Booster Exemption Record on at the facility and no vaccination records on file at all for Staff 4 (S4). In addition, no records of Covid test results available at the facility as well for the non-vaccinated/boosted staff that filed for Exemption, if applicable. LPA Brown will be issuing a deficiency for failure to keep records of Worker’s Booster Vaccination/Exemption and Covid Test Results for non-vaccinated/boosted staff which can pose potential risk to residents in care.

An exit interview was conducted with Administrator Sulema Parra and a copy of this report (LIC809), LIC 809D, LIC9102 TA Advisory Notes and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/18/2022 02:11 PM - It Cannot Be Edited


Created By: Melody Brown On 05/18/2022 at 01:48 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: SULE'S LOVING HOME
FACILITY NUMBER: 361880704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
121125,120140,120275


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 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 the Licensee did not verify, worker's vaccination record, booster or exemption status or unvaccinated worker's test reusults as applicable by maintaining a record as required by State Public Officer Order of December 22, 2021which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2022
Plan of Correction
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Licensee stated that they will submit proof of Vaccination/Booster Vaccination/Exemption of Staff 2, Staff 3 and Staff 4 and Staff 5 by POC due date to LPA Brown and to update staff vaccination record for all staff at the facility 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: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022


LIC809 (FAS) - (06/04)
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