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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408342
Report Date: 12/19/2022
Date Signed: 12/19/2022 01:15:45 PM

Document Has Been Signed on 12/19/2022 01:15 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MANZANITA HOMEFACILITY NUMBER:
366408342
ADMINISTRATOR:TOLENTINO, JUDYFACILITY TYPE:
735
ADDRESS:720 MANZANITA COURTTELEPHONE:
(909) 391-9300
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 6CENSUS: 4DATE:
12/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Jaymark Arcibal- CaregiverTIME COMPLETED:
01:26 PM
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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 Caregiver Jaymark Arcibal and explained the purpose of the visit. At the time of visit there was three (3) staff and three (3) clients present. One (1) client was away from the facility.

During today's visit, 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 cough etiquette 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, disinfectant, surgical masks, N95 masks, and hand sanitizer. PPE was stored in a closet in the garage.

The facility staff has a plan in place to manage Covid-19 symptoms, which includes staff monitoring clients regularly for any changes in condition and daily temperature checks. The facility will contact the client's physician in the event of any Covid-19 related illnesses. There is a symptom screening of clients logged daily. The facility staff are responsible for cleaning and disinfecting the highly touched surface areas during their shift. All staff and clients are practicing all other precautions, which minimize the risk of them contracting Covid-19.

LPA toured the facilities interior and exterior and there were 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 Caregiver Jaymark Arcibal.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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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