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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425914
Report Date: 11/08/2022
Date Signed: 11/10/2022 10:54:58 AM


Document Has Been Signed on 11/10/2022 10:54 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:JULINDA'S HOME CAREFACILITY NUMBER:
366425914
ADMINISTRATOR:RODRIGUEZ, JULINDAFACILITY TYPE:
740
ADDRESS:13945 IVY AVE.TELEPHONE:
(909) 371-0314
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 2DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Julinda RodriguezTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst’s (LPA) Paola Guerrero and License Program Manager (LPM) Efren Malagon made an unannounced visit to the facility. The purpose of today's visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPAs met with Facility Administrator Julinda Rodriguez and Sherly Mandagi.

LPAs toured the facility and went over COVID-19 best practices for infection control and prevention with the Facility Administrator. 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 entrance of the facility has a check in process for visitors that includes a temperature and symptom check. The staff working at the facility were all wear proper face masks. The clients have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. The facility has postings throughout for proper cough etiquette, proper hand washing procedure, and/or social distancing guidelines. LPAs requested to inspect the facility's Personal Protective Equipment (PPE) supply. The facility has adequate amount of PPE supplies.

While touring the facility with administrator Sherly Mandagi LPA noticed that there were a lot of items blocking the water heater which can be a potential risk. Administrator indicated that they would work on removing the items and administrator will be providing pictures. LPA also noticed two additional rooms were added onto the garage however, county of San Bernardino did confirm that the facility does have permits for the added structure. LPA will follow up with fire department to ensure that the facility has an updated fire clearance if not LPA will request the home to be inspected by fire department. The facility will be issued a type B deficiency.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: JULINDA'S HOME CARE
FACILITY NUMBER: 366425914
VISIT DATE: 11/08/2022
NARRATIVE
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One (1) deficiency was issued per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report (LIC809), and the appeal rights were discussed and provided to Facility Administrator Juliana Rodriguez

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/10/2022 10:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: JULINDA'S HOME CARE
FACILITY NUMBER: 366425914

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by: The facility shall be clean, safe, sanitary, and in good repair at all time. Maintenance shall include provision of maintanence services and procedures for the safety and well-being of residents, employees and visitiors.
Deficient Practice Statement
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Based on the observation, the licensee failed to keep walkways from the garge clear which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2022
Plan of Correction
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Licensee agreed to clear walk-ways in the garge.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3