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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426087
Report Date: 05/09/2022
Date Signed: 05/09/2022 02:07:30 PM


Document Has Been Signed on 05/09/2022 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:A & K PRIVATE HOME CAREFACILITY NUMBER:
366426087
ADMINISTRATOR:VOODTIKON PHUMIRATFACILITY TYPE:
740
ADDRESS:11490 POPLAR STREETTELEPHONE:
9094781482
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 6DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Voodlikon Phumirat-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 Gardner met with Caretaker Fe Epres who confirmed that there are currently no cases/exposures of COVID-19 within the facility. Mrs. Epres called Administrator Voodlikon Phumirat who showed up to complete the visit today. At the time of visit there were two (2) staff, and six (6) residents present.

LPA Gardner went over COVID-19 best practices for infection control and prevention with Voodlikon Phumirat. The facility has a mitigation plan on file with licensing. LPA Gardner conducted a tour of the facility and made observations pertaining to the facility's infection control measures. LPA Gardner observed that 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 residents have hand sanitizer available to them throughout the facility. The bathrooms were stocked with hand soap and hands towels. LPA Gardner informed the facility they need to replace the hand towels with paper towels to help minimize the spread of COVID-19. LPA Gardner observed the facility to have multiple postings throughout the facility for 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 hallway cabinet. The facility has a full thirty (30) day supply of PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer supply. LPA Gardner inquired as to if staff have been fit tested for N95 masks, and Voodlikon Phumirat stated their staff have not been fit tested yet.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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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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: A & K PRIVATE HOME CARE
FACILITY NUMBER: 366426087
VISIT DATE: 05/09/2022
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LPA Gardner will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks and for not having paper towels in the bathroom. 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 Voodlikon Phumirat, along with copies of the TA Advisory Notes.

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

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC809 (FAS) - (06/04)
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