366408622-1-17-2025-56-AS-PGUO-DCZTTR-20250117140109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366408622
Report Date: 01/17/2025
Date Signed: 01/17/2025 02:01:19 PM

Document Has Been Signed on 01/17/2025 02:01 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	THELMA G. SMITH FAMILY CARE		FACILITY NUMBER:	366408622
ADMINISTRATOR/ DIRECTOR:	JOE ANN PAMILTON		FACILITY TYPE:	740
ADDRESS:	632 E. MAITLAND		TELEPHONE:	(909) 986-2124
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91761
CAPACITY: 4	TOTAL ENROLLED CHILDREN: 0	CENSUS: 1	DATE:	01/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Joe Ann Pamilton- Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility.The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with facility administrator Joe Ann Pamilton and was granted entry to the facility. The facility is a five (5) bedroom,(2), bathroom home and, with a kitchen/dining area, living room, no garage, and open driveway. The facility is an Residential Care Elderly designated home vendor by Inland Regional Center. Licensed capacity is (4) current census (1). LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be 110 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside locked cabinet inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Efren Malagon	TELEPHONE: (951) 202-6356
Paola Guerrero	TELEPHONE: (951) 473-7024
	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: THELMA G. SMITH FAMILY CARE	FACILITY NUMBER: 366408622
	VISIT DATE: 01/17/2025

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Record Review: LPA reviewed one (1) resident file for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. P&I was counted for and all matched with the ledger.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Joe Ann Pamilton.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025

LIC809 (FAS) - (06/04)

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