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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425621
Report Date: 06/15/2022
Date Signed: 06/15/2022 12:02:16 PM


Document Has Been Signed on 06/15/2022 12:02 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:CASA DE AMELIA ARF IIFACILITY NUMBER:
366425621
ADMINISTRATOR:SMITH, GLENFACILITY TYPE:
735
ADDRESS:4934 DELPHIN PLACETELEPHONE:
(909) 581-1803
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91737
CAPACITY:1CENSUS: 1DATE:
06/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Anna Smith- CaretakerTIME COMPLETED:
12:12 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 Gardner met with Caretaker Anna Smith who confirmed that there are currently no cases and or exposures of COVID-19 within the facility. At the time of visit there were (2) staff, one (1) client present.

LPA Gardner toured the facility inside and out and went over COVID-19 best practices for infection control and prevention with Anna Smith. LPA Gardner observed all staff members with a properly fitted face covering. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients, and properly caring for clients with COVID-19 positive results and/or exposures. 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. The client room has hand sanitizer, and the bathrooms were stocked with hand soap and paper towels. LPA Gardner observed the facility to have multiple postings throughout the facility for proper cough etiquette, proper hand washing procedure, and social distancing. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the bathroom cabinet. The facility has a full thirty (30) day supply of PPE items such as gloves, face shields, gowns, N95 masks, disinfectant, and hand sanitizer.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022
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 2


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: CASA DE AMELIA ARF II
FACILITY NUMBER: 366425621
VISIT DATE: 06/15/2022
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The client 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 Caretaker Anna Smith.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC809 (FAS) - (06/04)
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