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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413137
Report Date: 05/26/2022
Date Signed: 05/26/2022 11:42:40 AM

Document Has Been Signed on 05/26/2022 11:42 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:UNLIMITED QUEST INC ONTARIOFACILITY NUMBER:
366413137
ADMINISTRATOR:CHASE, TERESAFACILITY TYPE:
775
ADDRESS:1005 N BEGONIA AVETELEPHONE:
(909) 983-7437
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 45CENSUS: 43DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Program Director Cindy TrejoTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 05/26/2022 at 09:30 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Program Director Cindy Trejo 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 Program Director Trejo. Per documents review, Mitigation Plan was submitted 02/10/2021.

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 and all rooms and 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 Program Director Trejo in relation to COVID-19 and Program Director Trejo 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 Program Director Trejo informed LPA Brown that all staff have not been fit tested at this time. LPA Brown will be issuing a deficiency during today's inspection for staff not being fit tested for N95 masks due to the facility just had covid positive client last 04/18/2022, and N95 masks needs 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: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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: UNLIMITED QUEST INC ONTARIO
FACILITY NUMBER: 366413137
VISIT DATE: 05/26/2022
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Additionally, LPA Brown observed most clients and staff 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 Program Director Trejo with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

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 05/26/2022 at 10:00 AM, LPA Brown observed Staff 1, Staff 3, Staff 5, Staff 6, Staff 7, Staff 8, Staff 9, Staff 10, Staff 11, Staff 12, Staff 13 are all vaccinated and boosted. However, no booster vaccination/exemption for Staff 2 and Staff 4 maintained at the facility. LPA Brown will be issuing a deficiency for this item as this poses a potential risk to clients in care..

An exit interview was conducted with Program Director Cindy Trejo and a copy of this report (LIC809), LIC 809D and Appeal Rights were discussed and provided.

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

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/26/2022 11:42 AM - It Cannot Be Edited


Created By: Melody Brown On 05/26/2022 at 11:04 AM
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: UNLIMITED QUEST INC ONTARIO
FACILITY NUMBER: 366413137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82072(a)(2)
Personal Rights
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

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 providing all staff who interact with clients with fit testing for N95 respirators which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2022
Plan of Correction
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3
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Licensee stated to provide N95 respirator fit test to all staff and submit proof to LPA Brown by POC due date..
Type B
Section Cited
HSC
121125,120140,120275


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 ensuring the personal rights of persons in care to be in a safe, healthy comfortable facility failed to comply with reporting and personnel requirements and engaged in conduct inimical to the health, welfare and safety of persons in care in that the licensee did not verify workers vaccination, booster or exemption status or unvaccinated workers test result as applicable by maintaining a record as required by State Public Officer Order of December 22, 2021 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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Licensee stated to submit proof of booster vaccination record/exemption for Staff 2 and Staff 4 by POC due date to LPA Brown.
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: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
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