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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366401842
Report Date: 12/23/2022
Date Signed: 12/23/2022 11:41:49 AM

Document Has Been Signed on 12/23/2022 11:41 AM - 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:SALEM CHRISTIAN HOMES, INC.FACILITY NUMBER:
366401842
ADMINISTRATOR:BRENDA NAJARFACILITY TYPE:
735
ADDRESS:12487 LEWIS AVENUETELEPHONE:
(909) 248-0507
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 6CENSUS: 6DATE:
12/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Rebecca Pantoja- Direct Support PersonTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Direct Support Person (DSP) Rebecca Pantoja whom was explained the purpose of the visit. At the time, there was one (1) staff and one (1) client present at the facility.

LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. The entrance of the facility has a check in process for staff and visitors that includes a temperature and symptom check. LPA observed postings for handwashing and proper infection control signage throughout. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towels). LPA observed a thirty (30) day supply of Personal Protective Equipment (PPE) which includes gloves, gowns, surgical masks, N95 masks, and hand sanitizer. PPE was stored in the linen closet.

The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating and caring for clients with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases, 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.

The tour of the facilities interior and exterior indicated no health and safety concerns.

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 a copy of this report (LIC809) was provided to DSP Rebecca Pantoja.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2022
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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