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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881010
Report Date: 04/25/2022
Date Signed: 05/02/2022 09:31:11 AM

Document Has Been Signed on 05/02/2022 09:31 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:PAMPUS FAMILY HOMEFACILITY NUMBER:
331881010
ADMINISTRATOR:JENNIFER GETHERALLFACILITY TYPE:
735
ADDRESS:11545 PAMPUS DR.TELEPHONE:
(951) 332-6092
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY: 4CENSUS: 0DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennifer Getherall/LicenseeTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Amy Goldenberg is conducting a required annual. This is an adult facility that is not yet verndorized through the regional center and there are currently no residents.

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and has a limited supply of Personal Protective Equipment (PPE). LPA discussed the availability of additional PPE supplies to the facility at the time of this visit and advised the facility representatives to contact our office in the event additional supplies are necessary. LPA reminded Jennifer to contact their LPA any resident moves into the home.

Based on observations made during today’s inspection, there are no deficiencies being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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