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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425976
Report Date: 09/09/2022
Date Signed: 09/09/2022 03:41:39 PM


Document Has Been Signed on 09/09/2022 03:41 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:KATE'S HOME PROGRAMFACILITY NUMBER:
366425976
ADMINISTRATOR:ORVILLE DYFACILITY TYPE:
740
ADDRESS:7685 TANGELO AVE.TELEPHONE:
(909) 823-1344
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:6CENSUS: 4DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:24 PM
MET WITH:Orville DyTIME COMPLETED:
03:43 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno 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 Licensee Orville Dy who confirmed that there are currently no active cases of COVID-19 within the facility. Licensee Zenaida Dy was phoned and arrived at the facility during today's visit.

During the inspection, LPA Bueno and Licensee Dy conducted a brief tour of the inside and outside of the facility and made observations pertaining to the facility's infection control measures. The facility is equipped with sufficient hand hygiene and cleaning/disinfecting supplies. 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 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 also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the client presents any COVID-19 symptoms.

LPA Bueno observed all utilities were in use. The fire extinguisher was last inspected on 8/19/22. The facility has operating fire alarm and carbon monoxide detector. LPA observed no health and safety concerns at the time of visit.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted where this report was discussed and provided to Licensee at the conclusion of the inspection.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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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