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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880937
Report Date: 09/22/2022
Date Signed: 09/22/2022 09:20:23 AM

Document Has Been Signed on 09/22/2022 09:20 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:DAWSON HOMES INC. ON NICHOLAS COURTFACILITY NUMBER:
361880937
ADMINISTRATOR:HAWTHORNE, KENDRAFACILITY TYPE:
735
ADDRESS:1352 NICHOLAS CTTELEPHONE:
(909) 258-3241
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 4CENSUS: 0DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Kendra HawthorneTIME COMPLETED:
09:21 AM
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Licensing Program Analyst (LPA) Anna Bueno made an announced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA met with administrator Kendra Hawthorne who stated that the facility is going through vendorization with Inland Regional Center. There are no clients in the facility.

During today's visit, LPA and Administrator toured the facility and made observations pertaining to the facility's infection control measures. Although there is a limited supply of Personal Protection Equipment (PPE) on site, Administrator Hawthorne states that they do have PPE at another facility. 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.

LPA and Administrator toured the home. There are no bodies of water. LPA Bueno observed utilities in use except for gas. Smoke detectors and carbon monoxide alarms are operating. All bedrooms have the required furniture and lighting. The physical plant appears to be in operational compliance. 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 Administrator Hawthorne.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
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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