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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880952
Report Date: 09/21/2021
Date Signed: 09/21/2021 10:17:16 AM

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:R CARE HOME FOR SENIORS, LLCFACILITY NUMBER:
361880952
ADMINISTRATOR:RIVERA, AGNESFACILITY TYPE:
740
ADDRESS:4287 ORCHARD STREETTELEPHONE:
(818) 398-4102
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY:6CENSUS: 5DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Agnes RiveraTIME COMPLETED:
10:25 AM
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On 9/21/21 Licensing Program Analyst (LPA) Anna Bueno arrived at the facility to conduct an unannounced annual inspection, with an emphasis on infection control. LPA met with caregiver, Marife Brillantes, who was explained the nature of the inspection and LPA granted entry into the facility. There are currently 5 residents at the facility. Covid-19 risk assessment was conducted verbally with Brillantes and it was confirmed that there are no active and/or suspected COVID-19 cases in the facility. Administrator Agnes Rivera arrived shortly.

LPA toured the facility with the caregiver. There is a mitigation plan in place to help mitigate the spread of COVID-19 in the facility. There is one point of entry for routine COVID-19 symptoms screening is initiated for all residents, staff and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients. LPA observed hand sanitizer throughout the facility. LPA observed a sufficient supply of hand hygiene, cleaning and disinfecting items. LPA observed a sufficient supply of Personal Protective Equipment (PPE) that included surgical masks, gloves, hand sanitizer, and alcohol. The facility has a designated infection control person who is responsible for ensuring that the facility is compliance with infection control practices. The facility has a COVID mitigation plan in place, which outlines testing requirements, isolating/quarantining positive COVID-19 cases, proper cleaning, sanitizing, disinfecting, and monitoring of individuals for COVID-like symptoms. The facility is aware that it is mandatory that CCL is contacted if anyone tests positive for COVID-19.

According to California Code of Regulations, Title 22, Division 6, there were no deficiencies observed or cited during this visit. An exit interview was conducted where this report was discussed with and provided to Rivera.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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