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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426106
Report Date: 09/03/2020
Date Signed: 09/04/2020 07:26:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 600
RIVERSIDE, CA 92501
FACILITY NAME:PENNACLE FOUNDATION INCFACILITY NUMBER:
336426106
ADMINISTRATOR:CAROLYN RUFFINFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:6CENSUS: 3DATE:
09/03/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Executive Director (ED), Carolyn Ruffin TIME COMPLETED:
11:29 AM
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This is a continuation of a Pre-Licensing STRTP tele inspection conducted via Google Duo that was initiated on 08/05/2020. Licensing Program Analyst Jose Gonzalez contacted and met with Executive Director (ED), Carolyn Ruffin to continue with the Pre License STRTP tele inspection. LPA reviewed both client and staff files with ED. ED provided LPA copies of the missing documents for both clients and staffs files. LPA also conducted interviews with direct care staff and facility social worker. LPA informed ED that she needs ongoing training with direct care staff and follow up with direct care staff on emergency intervention plan, location and information of the needs and services plans for the clients. LPA also informed the ED that she needs to continue with the STRTP process of being accredited and having a mental health component.

LPA informed ED that Pre STRTP tele inspection has been completed and that she needs to continue to remain in compliance with the latest version of STRTP regulations.

A copy of this report was given and explained to Executive Director, Carolyn Ruffin who agreed to sign and email signed reports to LPA. Signed reports will be placed in the facility file.

SUPERVISOR'S NAME: Christina BarnesTELEPHONE: (951) 320-2025
LICENSING EVALUATOR NAME: Jose GonzalezTELEPHONE: (951) 897-8219
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2020
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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