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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412142
Report Date: 09/01/2022
Date Signed: 09/01/2022 10:34:36 AM


Document Has Been Signed on 09/01/2022 10:34 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: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:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Jocelyn Delgado- AdministratorTIME COMPLETED:
10:43 AM
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Licensing Program Analyst (LPA) Ryan Gardner 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.

LPA Gardner met with Caregiver Charlie De Leon and was granted entry to the facility. At the time of entry there were three (3) staff, and four (4) residents present. Administrator Jocelyn Delgado arrived at the facility shortly after the visit started.

LPA Gardner toured the facility inside and out and went over COVID-19 best practices for infection control and prevention with Jocelyn Delgado. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents and properly caring for residents with COVID-19 positive results and/or exposures. 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 entrance of the facility has a check in process for visitors that includes a vaccination verification/negative COVID test check, a temperature check, and a symptom check. The staff working at the facility were all properly fitted with a face mask. The residents have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. The facility has postings throughout the facility for proper cough etiquette, proper hand washing procedure, and/or social distancing guidelines. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the garage. The facility has a full thirty (30) day supply of PPE such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: M.A.M. FAMILY HOME 1
FACILITY NUMBER: 366412142
VISIT DATE: 09/01/2022
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All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

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 this report was discussed and provided to Administrator Jocelyn Delgado.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC809 (FAS) - (06/04)
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