<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200202
Report Date: 10/26/2021
Date Signed: 10/26/2021 01:56:54 PM

Document Has Been Signed on 10/26/2021 01:56 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTSFACILITY NUMBER:
198200202
ADMINISTRATOR:BEVERLY BRINSONFACILITY TYPE:
735
ADDRESS:14004 DAPHNETELEPHONE:
(310) 560-7975
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 3DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:Beverly Brinson-Licensee TIME COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/26/2021, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Licensee/Administrator Beverly Brinson and explained the purpose of today’s visit is to complete the infection control annual. The facility is licensed for six (6) ambulatory clients between the ages of 18-59.

The facility is a one-story home located in a residential neighborhood. The facility consists of the following: 3 resident bedrooms, 1 resident bathroom, a staff bathroom and bedroom, dining area, kitchen, living room, laundry area, shaded outdoor activity areas.

LPA and administrator toured the physical plant. There were no obstructions on the premises or small bodies of water. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Facility has one fire extinguisher which is fully charged.

During the visit, LPA observed the facility infection control practices. LPA reviewed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted and available.

No deficiencies were cited during this inspection visit.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

An exit interview was conducted and a copy of this report was provided to Beverly Brinson Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7