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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366427078
Report Date: 09/02/2022
Date Signed: 09/02/2022 04:30:59 PM

Document Has Been Signed on 09/02/2022 04:30 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:HOLLY LAND CARE HOMEFACILITY NUMBER:
366427078
ADMINISTRATOR:PENDINGFACILITY TYPE:
735
ADDRESS:2044 HOLLY AVENUETELEPHONE:
(909) 972-8497
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 6CENSUS: 4DATE:
09/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:53 PM
MET WITH:Oliver Dineros, AdministratorTIME COMPLETED:
04:35 PM
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Licensing Program Analysts (LPAs) Anna Bueno and Rayshaun Nickolas conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on infection control. LPA met with care staff who was informed of the nature of the visit. Administrator Oliver Dineros was phoned by staff and Administrator arrived at the facility during the visit.

During the inspection, LPAs and care staff conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. LPAs observed that the facility had several COVID-19 related postings throughout the facility. The facility was also equipped with sufficient hand hygiene supplies and cleaning and disinfecting provisions. This 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 clients regularly for any changes in condition and to subsequently notify the responsible parties and medical personnel in the event the client presents with any COVID-19 symptoms.

During today's visit, the facility appears to be meeting operational requirements. LPAs Bueno and Nickolas observed all bedrooms and bathrooms with appropriate furnishings and working appliances. All utilities are actively used during today's visit. Combination smoke alarm and carbon monoxide detector is functioning and charged fire extinguisher was last inspected on 5/19/2022. LPAs observed a 2 day supply of perishable food items and 7 days for non-perishables.

LPAs 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 of Regulations. An exit interview was conducted where a copy of this report was discussed and provided to Mr. Dineros at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2022
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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