361881005-11-30-2021-18-AS-ABUO-C99Q3X-20211130104928

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881005
Report Date: 11/30/2021
Date Signed: 11/30/2021 10:49:39 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:	A AND E LOVING SENIOR HOME CARE, INC.		FACILITY NUMBER:	361881005
ADMINISTRATOR:	BERNARDO, RUSSELL		FACILITY TYPE:	740
ADDRESS:	14931 OAKSPRING DRIVE		TELEPHONE:	(909) 320-7888
CITY:	FONTANA	STATE: CA	ZIP CODE:	92336
CAPACITY:	6	CENSUS: 5	DATE:	11/30/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Russell Benardo		TIME COMPLETED:	09:55 AM

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Licensing Program Analysts Rohit Lama, Bernadette Allen, and Anna Bueno made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPAs identified themselves to Administrator, Russell Bernardo and discussed the purpose of the visit. Prior to entry, facility Staff #1 (S1) required LPAs to get temperature checks and ensured that LPAs were masked. Administrator stated that all staff and residents were fully vaccinated and there were no recent positive COVID test results nor were there any individuals currently with COVID symptoms.

Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, and no deficiencies were noted.

During the inspection, LPA’s Allen, Lama and Bueno interviewed the Administrator pertaining to the facility's infection control measures and other health and safety concerns. LPA’s observed necessary signs posted in the facility, including signs related to COVID-19, which were in accordance with the Department's guidelines. The Administrator stated that the facility is equipped with sufficient PPE, hand hygiene supplies, and sufficient cleaning/disinfecting provisions. LPAs observed that the facility staff were wearing face coverings.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A AND E LOVING SENIOR HOME CARE, INC.	FACILITY NUMBER: 361881005
	VISIT DATE: 11/30/2021

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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 facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation of residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC809 (FAS) - (06/04)

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