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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401188
Report Date: 06/17/2022
Date Signed: 06/17/2022 03:23:07 PM

Document Has Been Signed on 06/17/2022 03:23 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:SALEM CHRISTIAN HOMES, INC.-"CASA PUENTE"FACILITY NUMBER:
366401188
ADMINISTRATOR:SORIA, ANGELINAFACILITY TYPE:
735
ADDRESS:2904 DEL NORTE PLACETELEPHONE:
(909) 923-1961
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 6CENSUS: 5DATE:
06/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Staff Rebecca PantojaTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 06/17/2022 at 12:40 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with staff Rebecca Pantoja and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Staff Pantoja reported that they have five (5) clients at the facility. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Staff Pantoja. Per documents review, Mitigation Plan was submitted 07/27/2021.

LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing, and signs have been posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect clients from infection during pandemic. LPA Brown toured the facility's and all rooms and bathrooms have hand soap and paper towels. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of PPE. LPA Brown went over the various recommended training for facility staff with staff Pantoja in relation to COVID-19 and staff Pantoja informed LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

LPA Brown inquired as to if staff have been fit tested for N95 masks, and staff Pantoja informed LPA Brown that two (2) staff have been fit tested but unable to show proof of completed N95 respirator fit test. Staff Pantoja also added that the rest of the staff already have an appointment scheduled for 06/22/2022 for N95 fit test. LPA Brown will be issuing a deficiency for this item due to the facility recently had COVID-19 positive clients last 01/21/2022, and N95 masks needs to be worn when a client is COVID-19 positive or under observation while awaiting test results LPA Brown observed most clients and most staff have been vaccinated and boosted and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: SALEM CHRISTIAN HOMES, INC.-"CASA PUENTE"
FACILITY NUMBER: 366401188
VISIT DATE: 06/17/2022
NARRATIVE
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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 proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their clients regularly for any changes in condition and to subsequently notify the clients physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During the tour of the facility on 06/17/2022 at 01:15 PM, LPA Brown observed broken window blind on one of the client bedrooms and also LPA Brown observed four (4) window screens in disrepair. LPA Brown informed staff Pantoja that deficiency will be issued for these items as these poses potential risk to clients in care.

Moreover, per records review, LPA Brown observed Staff 2, Staff 3 and Staff 5 not associated at the facility. LPA Brown informed staff Pantoja that Staff 2, Staff 3 and Staff 5 criminal background clearance must be transferred to the facility and citation will be issued for this item.


During the visit, LPA Brown requested staff vaccination records and on 06/17/2022 at 01:50 PM, LPA Brown observed Staff 3, Staff 4, Staff 5 and Staff 6 with dose 1, dose 2 and booster vaccination records. However, LPA Brown observed Staff 1 and Staff 2 only have dose 1 and dose 2 and both have no record of booster vaccination/exemption at the facility. LPA Brown will be issuing a deficiency for this item as this pose potential risk to clients in care.

An exit interview was conducted with staff Rebecca Pantoja and a copy of this report (LIC809), LIC 809D, and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/17/2022 03:23 PM - It Cannot Be Edited


Created By: Melody Brown On 06/17/2022 at 02:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SALEM CHRISTIAN HOMES, INC.-"CASA PUENTE"
FACILITY NUMBER: 366401188

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Each client shall have personal rights including: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not providing N95 respirator fit test to all the staff at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2022
Plan of Correction
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2
3
4
Licensee stated to submit proof of completed N95 respirator fit test to LPA Brown by POC due date.
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview and record review, the licensee did not comply with the section cited above by having a broken window blind in one (1) cleint bedroom which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2022
Plan of Correction
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Licensee stated to replaced broken window blind in one (1) client bedroom and submit proof to LPA Brown by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/17/2022 03:23 PM - It Cannot Be Edited


Created By: Melody Brown On 06/17/2022 at 02:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SALEM CHRISTIAN HOMES, INC.-"CASA PUENTE"
FACILITY NUMBER: 366401188

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by having four (4) window screens in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2022
Plan of Correction
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Licensee stated to replace four (4) window screens in disrepair and submit proof to LPA Brown by POC due date.
Type B
Section Cited
CCR
80019(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not transferring the criminal background clearance of Staff 2, Staff 3 and Staff 5 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2022
Plan of Correction
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Licensee stated to submit proof of transfer of criminal background clearance of Staff 2, Staff 3 and Staff 5 to LPA Brown by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/17/2022 03:23 PM - It Cannot Be Edited


Created By: Melody Brown On 06/17/2022 at 02:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SALEM CHRISTIAN HOMES, INC.-"CASA PUENTE"
FACILITY NUMBER: 366401188

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
121125,120140,120276


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring the personal rights of persons in care to live in safe, healthy, comfortable home failed to comply with reporting and personnel requirements and engaged in conduct inimical to the health, welfare and safety of persons in care in that licensee did not verify, workers vaccination, booster or exemption status or unvaccinated workers test results as applicable by maintaining a record as required by State Publoc Order of December 22, 2021 which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2022
Plan of Correction
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Licensee stated to submit proof of Booster Vacciination/Exemption of Staff 1 and Staff 2 to LPA Btrown by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022


LIC809 (FAS) - (06/04)
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