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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601386
Report Date: 01/26/2022
Date Signed: 01/27/2022 07:26:01 AM

Document Has Been Signed on 01/27/2022 07:26 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:RUBY GEM HOME CAREFACILITY NUMBER:
198601386
ADMINISTRATOR:SAMONTE, MICHELLE TORRESFACILITY TYPE:
735
ADDRESS:836 HALLWOOD AVETELEPHONE:
(909) 447-4649
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 4DATE:
01/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:S-1 and House Manager/Lead StaffTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with S-1 and discussed the purpose of today's visit. House Manager/Lead Staff arrived at approximately 1:25 P.M..

This home consists of (4) private client bedrooms, (2) bathrooms, living room, kitchen, dinning area, storage room (laundry room inside the storage room)and attached garage. All Clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE and hygiene supplies observed (additional supplies stored inside the storage room).
  • Restrooms have hand soap, hand sanitizer and paper towels.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Additional food supply including water observed inside the garage.
  • Medication reviewed for (4) Clients (C-1 through C-4).
  • C-1 through C-4 are vaccinated. C-1 through C-3 also have the Booster. C-4 has the Booster pending.
  • There are a total of (7) staff working at this facility. (6) staff are vaccinated. (1) is not vaccinated and has an exemption on file.
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were be socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to House Manager/Lead Staff.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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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