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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412117
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:17:03 PM


Document Has Been Signed on 07/12/2022 03:17 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
, 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:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Jum Kim Administrator TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility to conduct an annual inspection focused on infection control. At 2:27 PM, LPA was greeted and granted entry by Jum Kim and she was informed of the purpose of the visit.

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 posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer). The staff was observed wearing appropriate face coverings (surgical masks) at the time of visit.

The facility staff has a plan to manage Covid-19 symptoms, which includes staff monitoring residents regularly for any changes in condition, which includes daily temperature checks. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility staff are responsible for cleaning and disinfecting the highly touched surfaces during their shift.

LPA toured the facility inside and out and there were no health and safety concerns.

The clients rooms had the required furniture and sufficient lighting. The bathrooms can accommodate the needs for bathing and showers & have non-slip flooring. The facility had a supply of additional linen and extra hygiene items for the clients.

The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors at the facility.

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 house manager Jun Kim

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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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