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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366403998
Report Date: 05/11/2022
Date Signed: 05/11/2022 12:19:12 PM

Document Has Been Signed on 05/11/2022 12:19 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:SCHONEVELD HOMEFACILITY NUMBER:
366403998
ADMINISTRATOR:THERESA SOTOFACILITY TYPE:
735
ADDRESS:3457 SOUTH WRANGLER PLACETELEPHONE:
(909) 923-7527
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 4CENSUS: 4DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Evelyn GreenTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 05/11/2022 at 9:15 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Staff Renee Morales and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Administrator Evelyn Green was contacted and arrived at the facility during the visit. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator Green. 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. LPA Brown toured the facility's client bedrooms and bathrooms and observed that both client 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 however, LPA Brown observed no available face shields/goggles at the facility. LPA Brown will be issuing a Technical Assistance Advisory Notes for not having face shield/goggles at the facility. Administrator Green informed LPA Brown that their main office will provide face shields/goggles and will submit a request today. LPA Brown went over the various recommended training for facility staff with Administrator Green in relation to COVID-19 and Administrator Green 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 Administrator Green informed LPA Brown that only Staff 2 and Staff 4 had been fit tested at this time and other staff - Staff 1, Staff 3, Staff 5, Staff 6, Staff 7 and Staff 8 have not been fit tested. LPA Brown will be issuing a deficiency during today's inspection for staff not being fit tested for N95 masks due to the facility having COVID-19 positive client last 01/24/2022, and N95 masks needs to be worn when a client is **** Continuation in LIC809C ****
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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 6
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: SCHONEVELD HOME
FACILITY NUMBER: 366403998
VISIT DATE: 05/11/2022
NARRATIVE
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COVID-19 positive or under observation while awaiting test results. Additionally, LPA Brown observed all clients have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown will be providing Administrator Green with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

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 visit, LPA Brown requested staff vaccination records and on 05/11/2022 at 10:15 AM, LPA Brown observed only four (4) staff with vaccination record and two (2) staff with Exemption Record on file. In addition, no available vaccination/booster records for all other staff at the facility and no records of Covid test results available at the facility as well for the non-vaccinated staff that filed for Exemption. LPA Brown will be issuing a deficiency for failure to keep records of Worker’s Booster Vaccination/Exemption and Covid Test Results for non-vaccinated staff which can pose potential risk to residents in care.

In addition, per records review, LPA Brown observed Staff 8 not associated at the facility. LPA Brown will be issuing a citation for not having Staff 8 associated at the facility as this poses potential risk to clients in care.

An exit interview was conducted with Administrator Evelyn Green and a copy of this report (LIC809), LIC 809D, LIC9102 TA Advisory Notes and Appeal Rights were discussed and provided.

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

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/11/2022 12:19 PM - It Cannot Be Edited


Created By: Melody Brown On 05/11/2022 at 11:46 AM
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: SCHONEVELD HOME
FACILITY NUMBER: 366403998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80078(a)
Responsibility for Providing Care and Supervision
(a)The licensee shall provide care and supervision as necessary to meet the client's needs.

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 providing all staff who are working with Covid-19 positive clients with fit testing for N95 respirators which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2022
Plan of Correction
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2
3
4
Licensee stated to have all staff N95 Fit tested 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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4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not transferring Staff 8 criminal background clearance at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2022
Plan of Correction
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4
Licensee stated that they will transfer Staff 8 criminal background clearance 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: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/11/2022 12:19 PM - It Cannot Be Edited


Created By: Melody Brown On 05/11/2022 at 11:56 AM
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: SCHONEVELD HOME
FACILITY NUMBER: 366403998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022

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


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 ensuring the personnel rights of persons in care to live in a safe, comfortable home failed to compoly with reporting and personnel requirements and engaged in conduct inimical to the health, welfare and safety of persons in care in that the licensee did not verify, workers vaccination, booster or exemption status or unvaccinated workers test results as applicable by maintaining a record at the facility as required by State Public Officer Order of December 22, 2021 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2022
Plan of Correction
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Licensee stated to submit proof of Booster Vaccination/Exemption and Weekly Covid Test Results of all staff that are not vaccinated to LPA Brown by POC due date and to update staff vaccination record/exemption for all staff at the facility 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: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022


LIC809 (FAS) - (06/04)
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