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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423836
Report Date: 03/11/2022
Date Signed: 03/11/2022 02:07:25 PM

Document Has Been Signed on 03/11/2022 02:07 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:LACEY MANORFACILITY NUMBER:
366423836
ADMINISTRATOR:WESTLING, TANNAFACILITY TYPE:
735
ADDRESS:6564 LACEY ST.TELEPHONE:
(909) 628-5826
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 4CENSUS: 2DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Tanna Westling- ADMINISTRATORTIME COMPLETED:
02:15 PM
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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 met with Administrator Tanna Westling who confirmed that there are currently no cases/exposures of COVID-19 within the facility. At the time of visit there were two (2) staff, and zero (0) residents present. The two (2) residents are away at school and at day program. LPA went over COVID-19 best practices for infection control and prevention with Mrs. Westling. The facility has a mitigation plan on file with CCL. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for residents has been updated. LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the in the garage. Mrs. Westling has a supply of PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer supply. LPA discussed creating a box, or similar, to have a supply of PPE ready that would be dedicated for isolation room, along with a trash can to put inside and outside of an isolation room. LPA inquired as to if staff have been fit tested for N95 masks, and Mrs. Westling stated their staff have not been fit tested yet. LPA will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. 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 Mrs. Westling along with a copy of the TA Advisory Note for N95 fit test for staff.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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