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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412333
Report Date: 03/22/2022
Date Signed: 03/22/2022 02:17:33 PM

Document Has Been Signed on 03/22/2022 02:17 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:SEVILLE CARE CENTERFACILITY NUMBER:
366412333
ADMINISTRATOR:CUELLAR, CARMENFACILITY TYPE:
735
ADDRESS:16186 SEVILLE AVETELEPHONE:
(909) 854-0979
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 4DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Carmen CuellarTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 03/22/2022 at 01:00 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrator Carmen Cuellar and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator Cuellar and Administrator Cuellar reported that Mitigation Plan was submitted 01/20/2021. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility and observed that client bathrooms have paper towels and hand soap. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, and face shields/goggles and isolation gowns. LPA Brown went over the various recommended training for facility staff with Administrator Cuellar in relation to COVID-19 and Administrator Cuellar reported that all staff were trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Cuellar informed LPA Brown that all staff have been N95 fit tested. Administrator Cuellar showed proof of completed N95 respirator fit testing for all staff to LPA Brown. Also, LPA Brown informed Administrator Cuellar that N95 masks needs to be worn when a client is COVID-19 positive or under observation while awaiting test results. Additionally, Administrator Cuellar reported that all residents and most staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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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: SEVILLE CARE CENTER
FACILITY NUMBER: 366412333
VISIT DATE: 03/22/2022
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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. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients for COVID-19, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their clients regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, Chapter 6 of the California Code of Regulations. An exit interview was conducted with Administrator Carmen Cuellar and a copy of this report (LIC 809) was discussed and provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
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