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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445201621
Report Date: 02/01/2021
Date Signed: 03/01/2021 10:27:30 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:DE UN AMORFACILITY NUMBER:
445201621
ADMINISTRATOR:FLETES, MARICELAFACILITY TYPE:
740
ADDRESS:460 EUREKA CANYON ROADTELEPHONE:
(831) 728-0303
CITY:CORRALITOSSTATE: CAZIP CODE:
95076
CAPACITY:25CENSUS: 15DATE:
02/01/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maricela FletesTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime with Maricela Fletes Administrator, Tryg Thorenson and Rebekah Bird-Wohlegmuth Health Facilities Evaluator (HFEN) California Department of Public Health. The purpose of the visit was to provide technical assistance For Infection Prevention and Control guidelines for Adult and Senior Care facilities. LPA conducted a virtual tour of the facility.

The following recommendations were discussed:

1. Document COVID 19 entry screening questions were asked and recorded in log book.
2. Take staff temperature upon entering and exiting facility after shift and record in log book.
3. Rearrange chairs in the living room and remove dinning room table chairs to maintain social distancing.
4. Maintain covered trash cans in designated Isolation rooms.

Informational Links provided to for PPE and disinfecting, PIN 20-23 Facility Entering and Exiting Strategies, and CDC List of COVID 19 symptoms.

Report reviewed with Maricela Fletes and copy emailed for signature purposes.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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