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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411439
Report Date: 09/09/2022
Date Signed: 09/09/2022 11:39:30 AM

Document Has Been Signed on 09/09/2022 11:39 AM - 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:DE RAMOS HOMEFACILITY NUMBER:
366411439
ADMINISTRATOR:DE RAMOS, ISABELITAFACILITY TYPE:
735
ADDRESS:5190 FAUNA STREETTELEPHONE:
(909) 626-0452
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 5CENSUS: 4DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Maria Cabanlit, care staffTIME COMPLETED:
11:43 AM
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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 care staff who confirmed that there are no active and/or suspected exposure cases of Covid-19. Care provider phoned Administrator Isabelita De Ramos who arrived during the visit.

LPA Bueno and Administrator De Ramos toured the facility inside and outside. The facility has no bodies of water. The facility has charged fire extinguishers, smoke alarms, and carbon monoxide detectors. Sharps and medications were kept in safe and locked cabinets. LPA observed at least two (2) days supply of perishable food items and seven (7) days supply of nonperishable food items. The client bedrooms had the required furniture and sufficient lighting. All utilities were in use during today's visit.

LPA observed one central entry point and sign-in policy has been designated for screening. Routine symptom screening has been initiated at entry for staff, clients, and visitors. LPA observed hand sanitizers throughout the facility and adequate supply of personal protective equipment (PPE) and cleaning and paper supplies. All residents have at least a 30 day supply of medications.

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 De Ramos at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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