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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881034
Report Date: 01/25/2022
Date Signed: 01/26/2022 03:22:52 PM

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:BROOKDALE LOMA LINDAFACILITY NUMBER:
361881034
ADMINISTRATOR:ADAMS, LUCINDAFACILITY TYPE:
740
ADDRESS:25585 VAN LEUVEN STREETTELEPHONE:
(909) 796-5421
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:220CENSUS: 120DATE:
01/25/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ashley FifeTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA met with Business Manager Ashley Fife and explained the purpose of the visit. There are currently no cases of COVID-19 within the facility.

Upon entry, facility staff followed protocol and had LPA sign in, use sanitation gel, and show proof of vaccination. LPA toured facility with MS Fife and observed areas of the facility to clean and free of clutter. LPA asked MS Fife questions related to staff and resident vaccination and it appears to this LPA that procedures are being followed per COVID prevention protocols.

LPA Prieto was experiencing computer malfunctions that prohibited the conclusion of an annual inspection. The computer malfunction detoured ability for facility staff and LPA to sign Facility Evaluation Report (LIC 809) at time of visit. MS Fife was notified that a continuation annual inspection will be conducted at a later date (01/27/2022).

LPA Prieto phoned the facility and obtained a FAX contact number to obtain a handwritten signature.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
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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