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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409395
Report Date: 03/24/2022
Date Signed: 03/24/2022 10:32:25 AM

Document Has Been Signed on 03/24/2022 10:32 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:WHITAKER HOMEFACILITY NUMBER:
366409395
ADMINISTRATOR:JENNIFER WHITAKERFACILITY TYPE:
735
ADDRESS:721 N. EUCLID AVENUETELEPHONE:
(909) 579-0164
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 3DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Ronald WhitakerTIME COMPLETED:
10:43 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA met with Licensee Ronald Whitaker who confirmed that there are currently no cases/exposures of COVID-19 within the facility. At the time of visit there were two (2) staff, and one (1) resident present. Two (2) residents were away at day program. Upon observation and interview, LPA Gardner discovered that Priscilla Whitaker was living at the facility without background clearance. Ms. Whitaker has been living at the facility for seven (7) days. LPA Gardner will be issuing a citation to the facility for allowing Ms. Whitaker to live at the facility without background clearance. LPA Gardner observed Mr. Whitaker walk Ms. Whitaker out of the facility.

LPA Gardner went over COVID-19 best practices for infection control and prevention with Mr. Whitaker. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA Gardner observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for residents has been updated. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was in the hall closet. Mr. Whitaker has a full 30-day supply of PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer supply. LPA Gardner discussed creating a cart, or similar, to have a supply of PPE ready that would be dedicated for isolation room, along with a trash can to put inside and outside of an isolation room. All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

..-Continued on LIC809-C...
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: WHITAKER HOME
FACILITY NUMBER: 366409395
VISIT DATE: 03/24/2022
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...Continued from LIC 809...

Based on the observations made during today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Mr. Whitaker, along with LIC809-C, LIC809-D, LIC421BG, LIC811, and appeal rights.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2022 10:32 AM - It Cannot Be Edited


Created By: Ryan Gardner On 03/24/2022 at 09:52 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: WHITAKER HOME
FACILITY NUMBER: 366409395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
80019(e)(1)
80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or..

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in by allowing NCR(non-client resident) to live in the facility for seven (7) days without background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2022
Plan of Correction
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The licensee removed NCR(non-client resident) upon LPA review. The licensee agreed to read regulation 80019 entirely. The licensee will provide self certify letter that the regulation was read and understood. The licensee agreed to not allow NCR(non-client resident) to live in the facility until they have fully completed the background clearance.
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:Karen Clemons
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022


LIC809 (FAS) - (06/04)
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