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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601569
Report Date: 09/07/2022
Date Signed: 09/07/2022 03:56:52 PM

Document Has Been Signed on 09/07/2022 03:56 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 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: 4DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Brenda Watkins TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with administrator Brenda Watkins and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed clients and staff files.

The facility is a single story house and located in a residential neighborhood area. The facility includes living room, four clients bedrooms, two bathrooms, dining area, kitchen/laundry area and a detached garage. All 4 clients bedrooms were toured. Each client bedroom has one bed, dresser, night stand, chair and required bed linen and furniture and sufficient lighting and closet space. All 2 bathrooms were toured and they were clean, sanitary and in a operable condition. The hot water temperature in both bathrooms were tested between 117.4 and 118.2 degrees F. which is within the Title 22 regulation. The refrigerator and kitchen cabinet consisted of two days perishable and seven days non-perishable food supply. All the appliances in the kitchen are working properly. The common area such as living room and dining area are clean and have required furniture. The front and back yard are maintained well and the back yard has a shaded area with table and chairs for client to utilize. LPA also inspected the smoke detectors and carbon monoxide detectors and they are all working well.

LPA reviewed all 4 clients files to confirm emergency contact is updated. LPA also reviewed 2 staff files to confirm health screenings and fingerprint clearances and they are all fingerprint cleared and their health screening forms were updated on the file. LPA also reviewed all 3 clients' medications and they all seemed accurate and updated.

See LIC 809C for continuation
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 198601569
VISIT DATE: 09/07/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility. The disinfecting products are available in each bathroom and common area and facility is disinfected every time client used. The bathrooms have sufficient soap, paper towels, and signs and PPE supplies are sufficient for more than 30 days.

No deficiencies were observed during the visit.

Exit interview conducted. A copy of the report was provided to administrator Brenda Watkins.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
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