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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425506
Report Date: 02/22/2022
Date Signed: 02/22/2022 11:49:47 AM

Document Has Been Signed on 02/22/2022 11:49 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
RIVERSIDE, CA 92507
FACILITY NAME:YUCAIPA ADULT DAY CENTERFACILITY NUMBER:
366425506
ADMINISTRATOR:MURRAY, SHARANFACILITY TYPE:
775
ADDRESS:12980 2ND STREETTELEPHONE:
(909) 790-4012
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 49CENSUS: 39DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Francisco GonzalezTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 02/22/2022 at 10:15 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrator Francisco Gonzalez 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 Francisco Gonzalez and Administrator Gonzalez reported that Mitigation Plan was submitted January 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 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 gowns, goggles but no face shields. LPA Brown went over the various recommended training for facility staff with Administrator Gonzalez in relation to COVID-19 and Administrator Gonzalez confirmed 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 Gonzalez informed LPA Brown that all staff have been N95 fit tested. A Medical Representative went to the facility and conducted N95 Fit Test to all the staff last 2020. Also, Administrator Gonzalez showed proof of N95 Fit Test Cards to LPA Brown. In addition, 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.
*** Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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
RIVERSIDE, CA 92507
FACILITY NAME: YUCAIPA ADULT DAY CENTER
FACILITY NUMBER: 366425506
VISIT DATE: 02/22/2022
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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 3 of the California Code of Regulations. An exit interview was conducted with Administrator Francisco Gonzalez and a copy of this report (LIC 809) was provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
LIC809 (FAS) - (06/04)
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