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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400754
Report Date: 01/04/2023
Date Signed: 01/04/2023 12:22:09 PM

Document Has Been Signed on 01/04/2023 12:22 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:KWIK BOARD AND CAREFACILITY NUMBER:
366400754
ADMINISTRATOR:KWIK, MELLY E.FACILITY TYPE:
740
ADDRESS:11642 PECAN WAYTELEPHONE:
(909) 376-3363
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 6CENSUS: 5DATE:
01/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Cheryl Soeoth, CaregiverTIME COMPLETED:
12:45 PM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Kwik Board & Care Facility to conduct an annual inspection with a focus on Infection Control. LPA introduced self and stated purpose of the visit, LPA was granted entry by staff member, Cheryl Soeoth, (S1) S1 contacted Administrator Melly Kwik, who arrived minutes later to provide LPA with walk through. LPA signed in an observed a COVID station equipped with hand sanitizer and PPE. Additional PPE observed in furnishing underneath COVID station. Administrator reports no suspected cases of COVID. All residents and staff are vaccinated.

During the inspection, LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA observed appropriate postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA observed that the Licensee wearing a mask during the visit. 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 (CCLD) guidelines for COVID-19 testing, isolating/quarantining 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. LPA reviewed resident records and interviewed Licensee.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KWIK BOARD AND CARE
FACILITY NUMBER: 366400754
VISIT DATE: 01/04/2023
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Fire and Carbon Monoxide alarms tested and found operational. Fire extinguisher last inspected 9/20/22. LPA walked through backyard and discovered pet doves secure in cage. Secure areas for yard tools. Residents medications observed securely kept in file cabinet in kitchen. Sharp objects, observed in secure in kitchen cabinet. A separate closet in the hallway is used to keep all facility cleaning solutions secure. LPA reviewed resident and staff charts and found charts were sufficiently recorded.

Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected, and no deficiencies were noted.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
LIC809 (FAS) - (06/04)
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