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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413179
Report Date: 02/08/2022
Date Signed: 02/08/2022 02:53:04 PM

Document Has Been Signed on 02/08/2022 02:53 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
RIVERSIDE, CA 92507
FACILITY NAME:ALYZA HOMEFACILITY NUMBER:
366413179
ADMINISTRATOR:FIGURACION, MARIOFACILITY TYPE:
735
ADDRESS:5062 RODEO STREETTELEPHONE:
(909) 270-3738
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 6CENSUS: 5DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Francis Pastorfide, AdministratorTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on the infection control domain. LPA met with administrator Francis Pastorfide who confirmed there are no active and/or suspected Covid-19 cases in the facility.

The facility submitted a mitigation plan to Community Care Licensing (CCL) to mitigate the spread of COVID-19 in the facility. Single entry point at the front door has a sign-in policy for universal entry screening. The facility also documents daily temperature and COVID-19 symptom checks for all visitors while clients are subject to routine symptom screening and regular observations for any change in condition. LPA observed all staff are properly fitted with face coverings.

LPA Bueno and Pastorfide tours the facility inside and out. The facility has charged smoke and carbon monoxide detectors and fire extinguishers. Hand sanitizer and masks are available near the front door. LPA Bueno and Pastorfide observed that the facility has an adequate supply of protective presonal equipment (PPE) cleaning and disinfectant provisions.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. LPA Bueno gave a technical advisory regarding fit testing for staff. An exit interview was conducted where this report was discussed, and a copy of this report was also provided to administrator at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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