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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880850
Report Date: 06/10/2021
Date Signed: 06/10/2021 01:01:28 PM

Document Has Been Signed on 06/10/2021 01:01 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:SALEM HOMEFACILITY NUMBER:
361880850
ADMINISTRATOR:KARAMOY, DINAFACILITY TYPE:
735
ADDRESS:18305 SALEM LANETELEPHONE:
(760) 596-1472
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 0DATE:
06/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Dina KaramoyTIME COMPLETED:
01:15 PM
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Licensing Program Analysts (LPAs) Natalie Gayoso and Anna Bueno made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPAs were met by Licensee Dina Karamoy. There are currently no clients in care as the facility is awaiting vendorization from Regional Center.

During today's visit, LPAs toured the facility and made observations pertaining to the facility's infection control measures. LPAs observed licensing issued signage throughout the facility. While there are no clients in care, Licensee Karamoy has proper COVID-19 signage posted. LPAs observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. 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 clients for COVID-19, 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 clients regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, there were no deficiencies cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided to the Licensee..
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Natalie Gayoso
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2021
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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