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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880949
Report Date: 09/17/2021
Date Signed: 09/17/2021 09:56:56 AM

Document Has Been Signed on 09/17/2021 09:56 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
RIVERSIDE, CA 92507
FACILITY NAME:KELLEY LIVING AT NORTONFACILITY NUMBER:
361880949
ADMINISTRATOR:KELLEY, SUCETFACILITY TYPE:
735
ADDRESS:12853 NORTON AVENUETELEPHONE:
(909) 270-0685
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 4CENSUS: 0DATE:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator Sucet KelleyTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control.

LPA Gardner met with Administrator Sucet Kelley. Present in the home during time of visit were no clients. There are currently no cases of COVID-19 within the facility. The facility is still waiting on vendors from IRC to obtain clients.

During today's visit, LPA Gardner toured the facility and made observations pertaining to the facility's infection control measures. LPA Gardner 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.

During the inspection LPA Gardner discussed infection control practices and procedures with Ms. Kelley.

An exit interview was conducted and a copy of this report, was reviewed with and provided to Ms. Kelley.

An exit interview to review this report was conducted and a copy of this report to Ms. Kelley.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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