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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601569
Report Date: 09/10/2021
Date Signed: 09/10/2021 11:46:01 AM

Document Has Been Signed on 09/10/2021 11:46 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:CARRUTHERS HOMEFACILITY NUMBER:
198601569
ADMINISTRATOR:BRENDA WATKINSFACILITY TYPE:
735
ADDRESS:2498 LEEBE AVETELEPHONE:
(909) 274-7554
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 4CENSUS: 3DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jimmy Watkins, lead caregiverTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Nicole Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Spencer was greeted by lead caregiver and discussed the purpose of today's visit. This single-story home contains four (4) bedrooms, two (2) bathrooms, a living room, kitchen, dining room, backyard, and detached garage.
The following was observed/inspected:
  • The facility had a universal entrance screening area including a screening sheet, thermometer, and hand sanitizer. A temperature check log for staff and residents was maintained daily.
  • COVID-19 signage was placed in several areas including entrance and common areas.
  • Facility maintained a 30-day supply of PPE.
  • Staff wore face masks throughout their shift and furniture was placed to encourage physical distancing.
  • There was a sufficient supply of 7-day non-perishable foods and a 2-day perishable foods.
  • Cleaning solutions and sharps were locked and inaccessible.
  • Water temperature was measured and were within required 105-120 degrees F.
  • All resident rooms contained required furniture including bed, dresser, night stand, lamp and chair.
  • Medications were locked and centrally stored and facility maintained a 30-day supply of medications.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Indoor/outdoor passageways were free from obstruction, clean, and in good repair.
  • A fire extinguisher was observed to be fully charged and last serviced on June 2021.
  • Client files were inspected and emergency contact information and health screenings were up to date for all clients.
  • Staff files were inspected and contained the required health screenings, criminal record clearances, and trainings.
  • Administrator certificate was inspected and had expired on 7/2021.
Pursuant to Title 22, a deficiency was cited on the attached 809D. An exit interview was conducted and a copy of this report and appeal rights were provided to the lead caregiver.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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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Document Has Been Signed on 09/10/2021 11:46 AM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 09/10/2021 at 11:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CARRUTHERS HOME
FACILITY NUMBER: 198601569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in due to an expired administrator certificate which expired on 7/8/21, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2021
Plan of Correction
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The administrator stated that she is in the process of getting the administrator certificate renewed and has already submitted the paperwork. The administrator will send a copy of the renewed administrator certificate to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2021


LIC809 (FAS) - (06/04)
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