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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402583
Report Date: 11/07/2022
Date Signed: 11/07/2022 10:47:31 AM


Document Has Been Signed on 11/07/2022 10:47 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:BROOKDALE NORTH EUCLIDFACILITY NUMBER:
366402583
ADMINISTRATOR:LISA TOFACILITY TYPE:
740
ADDRESS:1031 N EUCLID AVETELEPHONE:
(909) 391-2622
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY:140CENSUS: 73DATE:
11/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Emelie Franco-Wellsness Coridinator TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to conduct a required annual inspection, with an emphasis on infection control, due to the COVID-19 pandemic. LPA Bernadette Allen identified herself to the Emelie Franco- Wellness Coordinator, who was also informed of the purpose of the visit.

During the inspection, LPA Allen interviewed Emelie Franco regarding the facility's infection control measures and inspected the facility for regulatory compliance. There is a Mitigation Plan (LIC808) on file.

The (WC) stated that the facility does not currently have any COVID-19 cases.

LPA Allen observed appropriate postings in the facility, including personal rights and visitation policies, which were in accordance with the department's guidelines. LPA Allen observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA Allen observed that the facility staff were wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases 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 guidelines for COVID-19 testing, isolation, and properly caring for clients 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.

Furthermore, LPA Allen observed that the facility appeared to be meeting operational requirements. LPA Allen observed that all utilities and appliances were functioning properly, and all passageways clear of obstruction, including emergency exits.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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: BROOKDALE NORTH EUCLID
FACILITY NUMBER: 366402583
VISIT DATE: 11/07/2022
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The facility was equipped with sufficient food supply and emergency supplies. All inspected areas of the facility, including client’s bedrooms and restrooms, appeared clean and in good repair. LPA Allen observed no apparent health and safety risks at the time of visit.

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

An exit interview was conducted where this report was discussed, and a copy of this report was provided to Emelie Franco- Wellness Coordinator at the conclusion of the inspection

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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