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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880963
Report Date: 10/25/2021
Date Signed: 10/25/2021 04:20:19 PM

Document Has Been Signed on 10/25/2021 04:20 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:ESPERANZA'S PLACEFACILITY NUMBER:
361880963
ADMINISTRATOR:AGUILAR, DANETTEFACILITY TYPE:
735
ADDRESS:12104 MODOC PLACETELEPHONE:
(714) 483-8057
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 4CENSUS: 0DATE:
10/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Danette AguilarTIME COMPLETED:
04:23 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 3:55 PM and was informed that the facility currently has no clients in care as the facility is awaiting vendorization from Regional Center. There are no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. Although LPAs did not observed licensing issued signage throughout the facility, there are no clients in care and Licensee Aguilar will have proper COVID-19 signage posted prior to the first client admission. The home is currently utilized as a private home for Aguilar's family and cleaning and provisions will be made available when Regional Center vendorization is completed. 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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2021
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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