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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426354
Report Date: 02/22/2022
Date Signed: 02/22/2022 02:26:05 PM

Document Has Been Signed on 02/22/2022 02:26 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
RIVERSIDE, CA 92507
FACILITY NAME:XAVIER FAMILY HOMEFACILITY NUMBER:
366426354
ADMINISTRATOR:CARDEN, LORIFACILITY TYPE:
735
ADDRESS:9255 PALM LANETELEPHONE:
(909) 574-8129
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 4DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:House Manager Laporsha GrantTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 02/22/2022 at 12:30 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with House Manager Laporsha Grant 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 House Manager Laporsha Grant and House Manager Grant 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 face shields/goggles and isolation gowns. LPA Brown went over the various recommended training for facility staff with House Manager Grant in relation to COVID-19 and House Manager Grant reported that all staff were 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 House Manager Grant informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a technical violation during today’s inspection for staff not having been N95 fit tested due to the facility having covid positive client last 01/03/2022. Also, LPA Brown informed House Manager Grant that N95 masks needs to be worn when a client is COVID-19 positive or under observation while awaiting test results. Additionally, House Manager Grant reported that all residents and staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. Also House Manager Grant added that
*** 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: XAVIER FAMILY HOME
FACILITY NUMBER: 366426354
VISIT DATE: 02/22/2022
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all staff are scheduled for N95 Respirator Fit Test on 03/10/2022, between 12:00 PM to 01:00 PM.

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. 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.

An exit interview was conducted with House Manager Laporsha Grant and a copy of this report (LIC809) and LIC9102 AN Technical Violation were 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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