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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880901
Report Date: 07/08/2021
Date Signed: 07/08/2021 01:15:20 PM

Document Has Been Signed on 07/08/2021 01:15 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:B SMITH BOARD AND CAREFACILITY NUMBER:
361880901
ADMINISTRATOR:SMITH, BRITTNEYFACILITY TYPE:
740
ADDRESS:10583 PORTLAND AVETELEPHONE:
(909) 244-4280
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 4CENSUS: 2DATE:
07/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Brittney Smith TIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced to conduct health and safety check. At 10:24am, LPA was greeted and granted entry by an uncleared adult, Staff #1 (S1). LPA contacted Administrator via telephone and inquired about S1, and if they had been fingerprinted. Administrator Brittney stated that S1 had not been fingerprinted. LPA informed Administrator that S1 was not able to work at the facility until clearance has been granted and received. Immediate civil penalties will be assessed.

LPA George conducted a tour of the physical plant. The residents were groomed and had on appropriate clothing. The facility was clean and the passage ways were clear from obstruction. The facility is stocked with the required food minimums, which is a 2 day supply of perishables and a 7 day supply of non-perishable food items.


An exit interview was conducted and a copy of this report and appeal rights was provided to Administrator Brittney Smith.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2021
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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Document Has Been Signed on 07/08/2021 01:15 PM - It Cannot Be Edited


Created By: Javina George On 07/08/2021 at 11:21 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
RIVERSIDE, CA 92507

FACILITY NAME: B SMITH BOARD AND CARE
FACILITY NUMBER: 361880901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2021
Section Cited
CCR
87355(a)

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87355 Criminal Record Clearance
(b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement is not met as evidenced by: Based on observation, interview and record review the licensee did not ensure that staff obtained a criminal record clearance prior to beginning employment on 1 out of 1 times. This poses an immediate health, safety and personal rights risk to persons in care.
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The licensee will have S1 fingerprinted and submit proof to the department by 5pm on the due date indicated.

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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:Joel Esquivel
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2021


LIC809 (FAS) - (06/04)
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