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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412142
Report Date: 06/18/2021
Date Signed: 06/18/2021 12:23:51 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:M.A.M. FAMILY HOME 1FACILITY NUMBER:
366412142
ADMINISTRATOR:JDELGADO/MDELAROSAFACILITY TYPE:
740
ADDRESS:1181 KIRBY COURTTELEPHONE:
(909) 981-7911
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:6CENSUS: 4DATE:
06/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Lorfy DelgadoTIME COMPLETED:
12:29 PM
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Licensing Program Analysts (LPA) Natalie Gayoso and Anna Bueno made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPAs were granted entry by caregiver, Charlie De Leon. Caregiver contacted Licensee/Administrator Jocelyn Delgado. LPAs temperatures were screened upon arrival. De Leon confirmed that there are currently no positive cases or exposures of COVID-19 within the facility. Licensee Lorfy Delgado arrived shortly during the tour and LPAs explained the purpose of today's visit.

During the inspection, LPAs Gayoso and Bueno conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. LPAs observed appropriate postings throughout the facility, including self-monitoring/symptom assessment postings and hand-washing etiquette postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 30+ day supply of Personal Protective Equipment (PPE). LPAs Gayoso and Bueno also observed that all staff members were properly wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The facility continues to monitor residents regularly for their temperature, any changes in condition, and notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

LPAs Gayoso and Bueno observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, 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 Delgado at the conclusion of the inspection.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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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