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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400985
Report Date: 09/30/2021
Date Signed: 09/30/2021 01:23:47 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:ATRIA DEL REYFACILITY NUMBER:
366400985
ADMINISTRATOR:DEGUZMAN, SAMUELFACILITY TYPE:
740
ADDRESS:8825 BASELINE RDTELEPHONE:
(909) 989-4346
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:145CENSUS: 85DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Samuel DeguzmanTIME COMPLETED:
11:40 AM
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On 9/30/2021 Licensing Program Analyst (LPA) Shaunte Henry arrived at the facility to conduct an unannounced annual inspection with an emphasis on infection control. The LPA met with Executive Director (ED) Samuel Deguzman, explained the nature of the inspection and was granted entry into the facility. LPA’s temperature was taken with contactless thermometer and the LPA was screened for COVID-19 symptoms. There are currently 85 residents at the facility. As of this date, there are no positive COVID-19 cases or individuals with COVID-19 like symptoms present in the facility.

The LPA toured the facility with the Executive Director. The ED was advised to post additional signs regarding proper hand washing, cough/sneeze etiquette, and social distancing practices. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents via an application that is accessible to residents families. The LPA observed hand sanitizer throughout the facility. The LPA observed a sufficient supply of hand hygiene, cleaning and disinfecting items. The LPA observed a sufficient 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 symptoms. The facility is aware that it is mandatory that Community Care Licensing (CCL) is contacted if anyone tests positive for COVID-19.

According to California Code of Regulations, Title 22, Division 6, there were no deficiencies observed or cited during this visit. An exit interview was conducted where this report was discussed with and provided to the ED.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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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