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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366406352
Report Date: 03/08/2022
Date Signed: 03/08/2022 01:03:46 PM

Document Has Been Signed on 03/08/2022 01:03 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:OAK HILL HOMEFACILITY NUMBER:
366406352
ADMINISTRATOR:EVELYN GREENFACILITY TYPE:
735
ADDRESS:2420 S. OAK HILL DRIVETELEPHONE:
(909) 218-4936
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 4CENSUS: 4DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:26 PM
MET WITH:Evelyn Green-LICENSEETIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Ryan Gardner and Licensing Program Manager Karen Clemons made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA met with staff who confirmed that there are currently no cases/exposures of COVID-19 within the facility. At the time of visit there were 1 staff, and 3 participants present. Staff phoned Licensee who arrived during today's visit.

During the inspection, LPA conducted a tour of the facility and made observations pertaining to the facility's infection control measures. The facility is equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 30+ day supply of Personal Protective Equipment (PPE). 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. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients, 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 client presents any COVID-19 symptoms.

LPAs observed no health and safety concerns at the time of visit.

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

An exit interview was conducted, and a copy of this report was provided to Evelyn Green.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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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