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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366407059
Report Date: 06/20/2022
Date Signed: 06/20/2022 12:18:24 PM


Document Has Been Signed on 06/20/2022 12:18 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:RAINBOW GUEST HOMEFACILITY NUMBER:
366407059
ADMINISTRATOR:MENCIAS, MARIOFACILITY TYPE:
740
ADDRESS:11205 DAYLILLY ST.TELEPHONE:
(909) 357-0144
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY:6CENSUS: DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Mario MenciasTIME COMPLETED:
12:19 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on the infection control domain. LPA met with Mario Mencias, administrator, who confirmed there are no active and/or suspected Covid-19 cases in the facility.

The facility submitted a mitigation plan to Community Care Licensing (CCL) to mitigate the spread of COVID-19 in the facility. Single entry point to the main door has a sanitation station. The facility tracks daily temperature and COVID-19 symptom checks for all residents and staff however it is not documented. Residents are subject to routine symptom screening and regular observations for any change in condition. LPA observed all staff are properly fitted with face coverings.

LPA Bueno toured the facility inside and out. Smoke and carbon monoxide detectors were functioning. Fire extinguisher tag showing that last inspection date 05/27/21. LPA observed the facility has an adequate supply of cleaning and disinfectant provisions.

LPA observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, the facility is meeting operational requirements. 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 also provided to Administrator Mencias at the conclusion of the inspection.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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