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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409901
Report Date: 10/13/2022
Date Signed: 10/13/2022 02:54:56 PM

Document Has Been Signed on 10/13/2022 02:54 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:AMI-HOLLY HOUSEFACILITY NUMBER:
366409901
ADMINISTRATOR:VERGEL SANTOSFACILITY TYPE:
735
ADDRESS:15340 HOLLY DRIVETELEPHONE:
(909) 574-2577
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 5CENSUS: 3DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Vergel SantosTIME COMPLETED:
03:03 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Natalie Ibarra and Paola Guerrero made an unannounced visit to conduct an annual inspection, with emphasis on infection control. LPAs were greeted and allowed entrance by Direct Support Professional (DSP) Mary Kaseger. Administrator Vergel Santos was notified and arrived towards end of visit. DSP Kaseger accompanied LPAs on a tour of the facility.

LPAs toured the facility and made observations pertaining to the facility’s infection control measures. The reclients have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. Facility has sufficient hand hygiene, cleaning, and disinfecting supplies.. LPAs requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPAs observed one central entry point the included a temperature check. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in 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 client for COVID-19, 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 residents regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. During tour LPAs observed the side gate to be broken. A deficiency will be cited on the attached LIC 9099D

An exit interview was conducted, and a copy of this report, LIC 9099D, and Appeal Rights were discussed and provided to Administrator Vergel Santos.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Natalie Ibarra
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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Document Has Been Signed on 10/13/2022 02:54 PM - It Cannot Be Edited


Created By: Natalie Ibarra On 10/13/2022 at 02:47 PM
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
RIVERSIDE, CA 92507

FACILITY NAME: AMI-HOLLY HOUSE
FACILITY NUMBER: 366409901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the side gate is broken which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2022
Plan of Correction
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Licensee will fix gate and provide a picture showing gate fixed to LPA by end of POC date 10/20/22
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Natalie Ibarra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
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