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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881010
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:44:56 PM

Document Has Been Signed on 03/20/2024 04:44 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
SAN BERNARDINO ASC, 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:
03/20/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Jennifer Getherall/Administrator
TIME COMPLETED:
04:47 PM
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Licensing Program Analyst (LPA) Bianca Wolcott arrived announced to conduct an annual inspection. Upon arrival LPA was greeted by Jacqueline Bretz (Administrator) and Jennifer Getherall (Administration) and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. The facility has 4 client bedrooms, 2 bathrooms, kitchen, dining area, living room, laundry room, attached garage, and backyard. LPA completed a walk through of the facility and review of records.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 103 within range. LPA observed a locked cabinet in office with locked sharps. LPA observed in garage a locked cabinet with cleaning supplies and chemicals.

Fire extinguishers are charged and mounted. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility is maintained in conformity with the regulations adopted by the state fire marshal. Refrigerator is 37 degrees, and freezer is -0 degrees.

Personnel Records/Training/and Staffing-. LPA reviewed two (2) staff books for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. LPA observed First Aid Book available at facility.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PAMPUS FAMILY HOME
FACILITY NUMBER: 331881010
VISIT DATE: 03/20/2024
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Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental- LPA observed no residents at home so no books were provided.

Food Service- Food prep areas are clean and organized.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually, last done on 10/06/23. The facility is not conducting emergency disaster drills or fire drills due to no clients at this time.



No clients are living at residents.

This report was reviewed with and a copy provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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