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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412117
Report Date: 05/20/2021
Date Signed: 05/20/2021 01:58:48 PM

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:CAREGIVERS IIFACILITY NUMBER:
366412117
ADMINISTRATOR:JAEWON KIMFACILITY TYPE:
740
ADDRESS:10945 TRENMAR LANETELEPHONE:
(909) 877-0850
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY:6CENSUS: 6DATE:
05/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Caregiver Jum KimTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Caregiver Jum Kim and explained the purpose of the visit. The Administrator was unavailable, but met with LPA via telephone. At the time of visit there were two (2) staff and (6) residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings hung throughout the facility, the facility has an adequate amount of hand hygiene supplies, staff were also observed wearing appropriate face coverings (surgical masks).

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks, and will contact the resident's physician should there be any suspected COVID-19 related illnesses.

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 was provided to Caregiver Jum Kim.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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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