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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880977
Report Date: 11/04/2022
Date Signed: 11/04/2022 03:39:11 PM

Document Has Been Signed on 11/04/2022 03:39 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LEMON GRASS RESIDENTIAL CAREFACILITY NUMBER:
361880977
ADMINISTRATOR:HAIRE, JANECIAFACILITY TYPE:
735
ADDRESS:10832 LEMON GRASS AVE.TELEPHONE:
(909) 600-9790
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 4CENSUS: 0DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:42 PM
MET WITH:Janecia Haire, Licensee and Phalos Haire, DesigneeTIME COMPLETED:
03:45 PM
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LPA Amber Coleman (LPA Coleman) and LPA Anna Bueno (LPA Bueno) arrived at the facility to conduct an unannounced annual inspection with an focus on infection control. The LPAs met with licensees Janecia Haire and Phalos Haire, designee (Administrators)) who invited LPAs inside facility. LPAs discussed the purpose of the visit. LPA's were asked to have temperature taken and to sign in. Administrators informed LPAs there are currently no clients inhabiting the facility at this time.

LPAs and Administrators walked throughout the facility. Appropriate signage for infection control was observed throughout the facility's hallways and walls. Each bathroom included a sufficient supply of hand hygiene, cleaning and disinfecting items. The LPA observed extra supply of Personal Protective Equipment (PPE) that included surgical masks, N-95 masks, face shields, gloves, gowns, glasses, etc. 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-19 mitigation plan in place, which outlines testing requirements, isolating/quarantining positive COVID-19 cases, proper cleaning/sanitizing/disinfecting and monitoring of individuals for COVID-19 like symptoms. The facility is aware that it is mandatory that Community Care Licensing (CCL) is contacted if anyone tests positive for COVID-19. The facility overall was observed to be clean and orderly.

Fire and Carbon Monoxide Alarms were tested and found to be in proper working condition. Fire extinguisher last inspected March 7th, 2022.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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