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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601569
Report Date: 08/02/2024
Date Signed: 08/02/2024 01:44:12 PM

Document Has Been Signed on 08/02/2024 01:44 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CARRUTHERS HOMEFACILITY NUMBER:
198601569
ADMINISTRATOR/
DIRECTOR:		BRENDA WATKINSFACILITY TYPE:
735
ADDRESS:2498 LEEBE AVETELEPHONE:
(909) 274-7554
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 4CENSUS: 4DATE:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:52 AM
MET WITH:DSP Jimmie WatkinsTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with DSP Jimmie Watkins at approximately 11:52 AM and explained the reason for the visit.

The home is licensed to serve up to five (5) ambulatory disabled adults ages 18 - 59. The facility is a single-story house and located in a residential neighborhood area. The facility includes living room, dining area, kitchen, four (4) client bedrooms, two (2) client bathrooms and a detached garage.


LPA toured the facility and observed the following: Four (4) client bedrooms has the required furniture and bedding. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in the kitchen. Cleaning supplies and toxic substances are inaccessible to clients in a locked under sink. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked in cabinet in kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were not measured between the required range of 105-120 degrees F BR#1 103.9 and BR#2 103.4 deficiency cited. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The garage is clean and has a locked cabinet for cleaning supplies.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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 08/02/2024 01:44 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/02/2024 at 01:22 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: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above two bathrooms did not have the required water temperature BR#1 103.9 and BR#2 103.4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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DSP worker Jimmie Watkins adjusted water to required temperature during todays visit. Facility will keep a water log and test water twice a week and send log to LPA.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CARRUTHERS HOME
FACILITY NUMBER: 198601569
VISIT DATE: 08/02/2024
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Four (4) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Four (4) Client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Fire/earthquake drill was conducted on 07/10/2024. Infectious control plan will be emailed to LPA. The medications are centrally stored and locked in a cabinet in kitchen The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Robert Francisco. Annual fees are not current, and PIN was provided to Robert Francisco.


SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
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