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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412345
Report Date: 05/18/2022
Date Signed: 05/18/2022 05:49:34 PM

Document Has Been Signed on 05/18/2022 05:49 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:JUBILEE CARE HOMESFACILITY NUMBER:
366412345
ADMINISTRATOR:HERNANDEZ, NORMAFACILITY TYPE:
735
ADDRESS:1066 WINN DRTELEPHONE:
(909) 755-1178
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 4DATE:
05/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Administrator Oliver DinerosTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 05/18/2022 at 03:50 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrator Oliver Dineros 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 Dineros. Per documents review, Mitigation Plan was submitted 02/11/2021.

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's client bedrooms and bathrooms and observed that both client bathrooms have hand soap and paper towels. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of PPE. LPA Brown went over the various recommended training for facility staff with Administrator Dineros in relation to COVID-19 and Administrator Dineros informed LPA Brown that all staff are 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 Dineros informed LPA Brown that all staff have not been fit tested at this time. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive clients, and N95 masks only needing to be worn when a client is COVID-19 positive or under observation while awaiting test results.

**Continuation in LIC809C **
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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 6
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: JUBILEE CARE HOMES
FACILITY NUMBER: 366412345
VISIT DATE: 05/18/2022
NARRATIVE
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Additionally, most clients have been vaccinated and boosted and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown will be providing Administrator Dineros with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

During the visit, LPA Brown observed Staff 2 not wearing a mask. LPA Brown will be issuing a Technical Advisory Note as staff are required to wear mask while working at the facility.

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 and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients, 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 clients physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During the visit, LPA Brown requested staff vaccination records and on 05/18/2022 at 04:30 PM, LPA Brown observed all staff are vaccinated and boosted and there’s a staff vaccination record maintained at the facility. Moreover, LPA Brown observed Staff 1 (S1) not associated at the facility. LPA Brown will be issuing a deficiency for not Staff 1 not being associated at the facility as this poses a potential risk to clients in care..

Also, during the tour of the facility, LPA Brown observed no Emergency contact numbers posted at the facility. LPA Brown will be issuing a deficiency as this poses an immediate risk to clients in care. To add to that, no name and telephone number of an ambulance service posted at the facility as well. LPA Brown informed Administrator Dineros that citation will be issued as this poses an immediate risk to clients in care.

An exit interview was conducted with Administrator Oliver Dineros and a copy of this report (LIC809), LIC 809D, LIC9102 TA Advisory Notes and Appeal Rights were discussed and provided

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/18/2022 05:49 PM - It Cannot Be Edited


Created By: Melody Brown On 05/18/2022 at 05:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: JUBILEE CARE HOMES
FACILITY NUMBER: 366412345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(h)(2)
Health-Related Services
(h) There shall be at least one person capable of and responsible for communicating with emergency personnel in the facility at all times. The following information shall be readily available: (2) The name, address and telephone number of each emergency agency, including but not limited to the fire department, crisis center or paramedical unit. There shall be at least one medical resource available to be called at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview and record review, the licensee did not comply with the section cited above iby not having Emergency Contact Information posted at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2022
Plan of Correction
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Licensee stated to post Emergency Contact Information at the facility and submit proof to LPA Brown by POC due date.
Licensee will submit Statement of Understanding to CCR 80075(h)(2) and submit to LPA Brown by POC due date.
Type A
Section Cited
CCR
80075(h)(3)
Health-Related Services
(h) There shall be at least one person capable of and responsible for communicating with emergency personnel in the facility at all times. The following information shall be readily available: (3) The name and telephone number of an ambulance service.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having the name and telephone number of an ambulance service posted at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2022
Plan of Correction
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Licensee stated to post Name and Telephone Number of an Ambulance Service at the facility and submit proof to LPA Brown by POC due date.
Licensee will submit Statement of UNderstanding to CCR 80075(h)(3) and submit to LPA Brown by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/18/2022 05:49 PM - It Cannot Be Edited


Created By: Melody Brown On 05/18/2022 at 05:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: JUBILEE CARE HOMES
FACILITY NUMBER: 366412345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review], the licensee did not comply with the section cited above by not transferring the criminal background clearance of Staff 1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2022
Plan of Correction
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Licensee stated to submit a request of transfer of criminal background clearnace of Staff 1 and associate Staff 1 to the facility by POC due date and submit proof to LPA Brown.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022


LIC809 (FAS) - (06/04)
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