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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366410618
Report Date: 10/26/2021
Date Signed: 10/26/2021 03:55:27 PM

Document Has Been Signed on 10/26/2021 03:55 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
RIVERSIDE, CA 92507
FACILITY NAME:OHIO LANE MANORFACILITY NUMBER:
366410618
ADMINISTRATOR:HANNER, CYNTHIAFACILITY TYPE:
735
ADDRESS:7122 OHIO LANETELEPHONE:
(909) 823-7122
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 3DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:13 PM
MET WITH:Kristin McGee - AdministratorTIME COMPLETED:
03:56 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility for the purpose of conducting a required annual inspection with an emphasis on infection control. LPA was met by Administrator Kristin McGee, who confirmed there are no active and/or suspected Covid-19 cases in the home.

LPA toured the facility inside and out. The facility has no bodies of water. The facility has a charged fire extinguisher, smoke alarms, and carbon monoxide detectors. Cleaning supplies, medications, and sharps were kept in a safe and locked place. LPA observed more than two (2) days of perishable food items and seven (7) days of nonperishable food items. The client bedrooms had the required furniture and sufficient lighting. Facility had a supply of additional linen and hygiene items.

LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening for all visitors and weekly testing is conducted for unvaccinated staff. Facility continues to monitor any change in condition for staff and clients. LPA observed hand sanitizers and Covid-19 signages throughout the facility

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2021
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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