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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880863
Report Date: 08/16/2022
Date Signed: 08/16/2022 09:30:42 AM


Document Has Been Signed on 08/16/2022 09:30 AM - 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:ALOHA RESIDENTIAL CAREFACILITY NUMBER:
361880863
ADMINISTRATOR:KHAN, ASMATFACILITY TYPE:
740
ADDRESS:7476 BUNGALOW WAYTELEPHONE:
(951) 675-7763
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91739
CAPACITY:6CENSUS: 6DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ramoncito CruzTIME COMPLETED:
09:33 AM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPAs met with live-in staff who confirmed that there are currently no cases/exposures of COVID-19 within the facility. LPA phoned Licensee who arrived during today's visit.

During the inspection, LPA and staff conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was also equipped with sufficient hand hygiene and cleaning/disinfecting supplies. 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. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the client presents any COVID-19 symptoms.

LPA Bueno observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. A technical advisory (TA) was provided for maintaining a 30+ day supply of Personal Protective Equipment (PPE). An exit interview was conducted where this report and LIC 9102 (TA) were discussed and a copy was also provided to Licensee at the conclusion of the inspection.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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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