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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601386
Report Date: 01/20/2023
Date Signed: 01/20/2023 12:31:02 PM

Document Has Been Signed on 01/20/2023 12:31 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
GREATER LA AC/SC, 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:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Jesenia FloresTIME COMPLETED:
12:45 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
Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Jesenia Flores and discussed the purpose of today's visit.

This home consists of (4) bedrooms, (2) bathrooms, kitchen, dinning area, living room, storage/laundry room and attached garage. San Gabriel Pomona Regional Center provides case management services to all (4) clients from this home.

The following were observed/inspected: .
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Restrooms have hand soap, hand sanitizer and paper towels. Hand washing signs are also posted inside the bathrooms.
  • PPE supplies observed.
  • Hygiene supplies observed.
  • Hand sanitizer observed throughout the home.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Additional food supply is stored inside the garage.
  • Medication reviewed for (4) Clients (C-1 through C-4).
  • 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 Jesenia Flores.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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 1