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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392790075
Report Date: 10/13/2021
Date Signed: 10/13/2021 11:52:38 AM

Document Has Been Signed on 10/13/2021 11:52 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HAYNES BOARD AND CAREFACILITY NUMBER:
392790075
ADMINISTRATOR:PARKER, CHERYLFACILITY TYPE:
735
ADDRESS:17201 N. TULLY ROADTELEPHONE:
(209) 727-5834
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 30CENSUS: 23DATE:
10/13/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cheryl Parker and Sandra HaynesTIME COMPLETED:
12:00 PM
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On 10/13/2021 at 10am, Licensing Program Analyst (LPA) Ashley Boothe, arrived announced to conduct a conduct a Health and Safety visit based on a report of COVID-19 outbreak. LPA met with Administrators to tour the facility with Person one (P1), Infection Preventionist from California Department of Public Health Healthcare Associated Infections Program.

As of today, there are 12 positive residents of which 3 have cleared and 7 positive staff of which 5 have cleared and returned to work. Currently all residents are under isolation order due to the outbreak.

The team discussed infection control measures and mitigation of COVID-19 in the facility including but not limited to screening, isolation, disinfection, and use off personal protective equipment (PPE). Facility staff have not been fit tested for N95 respirators, Administrator stated FIT testing is in process. P1 is to deliver a report to the facility based on observations and discussions during today's visit. The Regional Office will continue to monitor the facility. Administrator requested PPE to be delivered to support on hand of PPE and LPA will coordinate delivery.

Per the California Code of Regulations, Title 22, Division 6, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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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