198601569-9-11-2023-28-AS-CDCN-CVKUHP-20230911153615

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601569
Report Date: 09/11/2023
Date Signed: 09/11/2023 03:37:18 PM

Document Has Been Signed on 09/11/2023 03:37 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:	CARRUTHERS HOME		FACILITY NUMBER:	198601569
ADMINISTRATOR:	BRENDA WATKINS		FACILITY TYPE:	735
ADDRESS:	2498 LEEBE AVE		TELEPHONE:	(909) 274-7554
CITY:	POMONA	STATE: CA	ZIP CODE:	91768
CAPACITY: 4		CENSUS: 4	DATE:	09/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:56 AM
MET WITH:	Jimmie Watkins, DSP Staff		TIME COMPLETED:	03:50 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) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with staff, Jimmie Watkins. The licensee, Brenda Watkins, arrived shortly thereafter to assist with the visit. The home is vendorized by the San Gabriel/Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the home. Infection Control: Staff are cleaning and disinfecting high touched surfaces daily. They are using appropriate hand hygiene and wearing gloves when necessary to assist clients. The facility has submitted the Infection Control Plan. Physical Plant & Environment Safety: The facility consists of 4 client bedrooms, 2 bathrooms, living room, kitchen, and a garage. There is a carbon monoxide detector located in the kitchen and smoke detectors in each room. Knives and cleaning solutions are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water was measured within the required range of 105 - 120 degrees F. Operational Requirements: The fire clearance is approved for (4) ambulatory clients. Staff are adhering to operational requirements as there are 4 ambulatory clients residing at the home. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The foods are properly stored in the refrigerator. Plates, cups and utensils are kept cleaned. Health Related Services: The medications are centrally stored and locked. LPA reviewed medications for all 4 clients and they are being administered as prescribed by the Physician and properly documented. Staffing: There is sufficient staffing at the facility. LPA verified the administrator submitted documents to renew the certificate prior to expiration date of 7/8/23. The HIV and TB Training certificate was completed on 4/23/23. Staff employed are fingerprint cleared and associated to the facility.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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 09/11/2023 03:37 PM - It Cannot Be Edited

Created By: Cynthia D Chan On 09/11/2023 at 02:32 PM

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: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff did not have current CPR & First Aid training which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	The administrator shall submit the current First Aid and CPR certificate for herself by POC date of 9/22/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Tony Vasallo

LICENSING EVALUATOR NAME:

Cynthia D Chan

LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: CARRUTHERS HOME	FACILITY NUMBER: 198601569
	VISIT DATE: 09/11/2023

NARRATIVE

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Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed files for 3 Staff. Staff files have current First Aid/CPR certification, Health Screening and Tuberculosis Screening on file except for one staff whose First Aid & CPR training expired on 5/7/23. Staff are receiving on-going training.
Client Rights-Information: There are no clients using postural supports. Clients are provided with internet access and devices.
Client Records-Incident Reports: LPA reviewed files for all 4 Clients. Client files are maintained at the facility. Each client file has the Admission Agreement, Physician's Report (including TB test results and Ambulatory Status), Weight Record, Consent Forms, Individual Program Plan/IPP, Client Rights, and Safeguarding forms for inventory and cash.
Incidental Medical Services: There are no clients with prohibited or restricted health conditions.
Disaster Preparedness: The facility has the updated Emergency Disaster Plan (LIC610D) in place.
Emergency Intervention: The staff do not utilize manual restraint but will use verbal redirection techniques to de-escalate a behavior.

There is one deficiency being issued today. An exit interview was held. A copy of this report along with appeal rights were provided to the administrator.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

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