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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800850
Report Date: 02/14/2022
Date Signed: 02/14/2022 11:28:53 AM

Document Has Been Signed on 02/14/2022 11:28 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PAYNE CARE CENTERFACILITY NUMBER:
197800850
ADMINISTRATOR:WILLIAMS, LAVONIA PAYNEFACILITY TYPE:
735
ADDRESS:181 E. ARROW HIGHWAYTELEPHONE:
(909) 506-4428
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 4DATE:
02/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Robyn Fleming (Administrator)TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. LPA met with Robyn Fleming (Administrator) and explained the purpose of the visit. The facility is licensed to serve ambulatory only, licensee can only serve developmentally disabled adults age 18 through 59.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, kitchen/laundry area, dining area, 4 Client bedrooms, 3 bathrooms, staff room and a detached garbage/office/storage.

During today’s visit, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. All clients are protected against hazards. All outdoor and indoor passageways are free of obstruction. There are no pools or large bodies of water on the premises. There are no firearms on the premises and other dangerous weapons such as knives are locked. Disinfectants, cleaning solutions, poisons are inaccessible to clients. A comfortable temperature for clients is maintained. Lamps or lights in all rooms to ensure the comfort and safety were observed. Hot water temperature measured at 117.9 degrees F in bathroom #1. All toilets, hand washing and bathing facilities is safe, sanitary and in operating condition. Hygiene products are readily available. All foods are selected, stored, prepared and served in a safe and healthful manner. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. Freezers and refrigerators are clean, and maintain temperatures. Smoke detectors and carbon monoxide detector is operable. Sufficient staff as necessary to ensure provision of care and supervision to meet client needs were observed. All staff have a criminal record clearance. Staff responsible for direct care and supervision have current first aid. The administrator is on the premises a sufficient number of hours necessary to adequately administer the facility in compliance with applicable law and regulation. All medications are labeled and maintained in compliance with label instructions and State and Federal law. Medications are safe, locked and inaccessible.

No deficiencies were observed during today's visit.
An exit interview was conducted and a copy of this report was provided to Robyn Fleming.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2022
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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