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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881089
Report Date: 04/08/2022
Date Signed: 04/08/2022 01:35:19 PM

Document Has Been Signed on 04/08/2022 01:35 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
, CA 92507
FACILITY NAME:EMERALD BOARD & CAREFACILITY NUMBER:
361881089
ADMINISTRATOR:GREGORIO, HAZEL ANNEFACILITY TYPE:
735
ADDRESS:18106 RAYMOND CTTELEPHONE:
(909) 320-8141
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 2CENSUS: 0DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Anita Gregorio-CaretakerTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Ryan Gardner 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. LPA Gardner met with Caretaker Anita Gregorio who confirmed that there are currently no cases/exposures of COVID-19 within the facility. At the time of visit the Caretaker Anita Gregorio and one (1) non-client resident were present. There are currently zero (0) clients living in the facility. The facility is waiting on placement from Inland Regional Center.

During today’s visit LPA Gardner toured the facility and made observations pertaining to the facility's infection control measures. LPA Gardner found that the facility does not have a mitigation plan on file with licensing. The facility was informed that they need to complete an LIC808 mitigation plan and email it to licensing for approval. LPA Gardner will be issuing a Technical Assistance Advisory Note during today's inspection for not having a mitigation plan on file. The facility needs to be ready to mitigate COVID-19 whether or not clients are present. The facility needs to put hand sanitizer in each client room. The facility needs to setup a sign in/temperature check procedure for clients as well as visitors. LPA Gardner did not observe any postings in the facility regarding cough etiquette, proper hand washing procedure, and social distancing. LPA Gardner emailed Ms. Gregorio COVID-19 sample posters to be posted in the facility. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in garage. The facility has a limited supply of PPE items due to not having clients living in the facility. LPA Gardner informed Ms. Gregorio that they need to obtain a full thirty (30) day supply of gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer supply.

...Continued on LIC809...
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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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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
, CA 92507
FACILITY NAME: EMERALD BOARD & CARE
FACILITY NUMBER: 361881089
VISIT DATE: 04/08/2022
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...Continued from LIC809...

LPA Gardner also discussed creating a box, or similar, to have a supply of PPE ready that would be dedicated for isolation room, along with a trash can to put inside and outside of an isolation room. LPA Gardner inquired if staff have been fit tested for N95 masks, and Ms. Gregorio stated their staff have not been fit tested yet due to not having clients living in the facility. LPA Gardner will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks.

Ms. Gregorio was informed that the facility needs to contact licensing when their first client moves into the facility for a post annual inspection. Licensing needs to come back to the facility to ensure the facility is properly setup to minimize the risk of incoming clients and staff contracting COVID-19.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Ms. Gregorio along with copies of the LIC 9102 forms, TA Advisory Notes.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
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