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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881010
Report Date: 04/26/2023
Date Signed: 05/04/2023 10:44:36 AM

Document Has Been Signed on 05/04/2023 10:44 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jennifer Getherall TIME COMPLETED:
11:00 AM
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 Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit to conduct a Required Annual inspection. LPA met with the licensee Jennifer Getherall. This Adult Residential facility is licensed for four (4) ambulatory clients.
LPA observed that there are currently no clients admitted to the facility. Licensee stated the facility intends to continue to be licensed however is waiting on vendorization through the Inland Regional Center. LPA toured the facility inside and out. There are no pools, bodies or water, firearms or ammunition. LPA observed the facility is kept at a comfortable temperature. Hot water was measured in the kitchen sink at 105 degrees Fahrenheit. LPA observed non-skid mats in showers and tubs. The client bedrooms have the required furniture and functional lighting. LPA observed a sufficient supply of towels, linens and personal hygiene items. Cleaning supplies were observed to be locked in the garage. The facility’s smoke detectors and carbon monoxide detectors were tested and are in working condition.
LPA observed the kitchen to be clean and free of odor. Appliances were observed to be operating. LPA did observe minimal food items as the facility has not had any clients in care. LPA observed where the client’s medications would be centrally located. Medication cabinet is observed to be secured and inaccessible to clients. The facility plans to have an appropriate number of staff present in the during operating hours and during the evening/sleeping hours when admitting clients in care.
LPA deferred reviewing client and staff files as the facility has no clients or staff in care. Administrator file was reviewed. LPA did not observe current HIV and TB training. Licensee agreed to provide training certificate to LPA. The facility had a first aid kit and manual available.
The patio area is shaded and has tables and chairs for client’s comfort. The back yard is completely enclosed and revealed no immediate hazards or obstructions.
No deficiencies issued per Title 22, Division 6 of the California Code of Regulations. One technical violation for the HIV and TB missing from Administrator file.
An exit interview was conducted where this report, LIC 809 and LIC 9102 was discussed and provided to Licensee Jennifer Getherall.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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