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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408622
Report Date: 02/09/2022
Date Signed: 02/09/2022 11:15:47 AM

Document Has Been Signed on 02/09/2022 11:15 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
RIVERSIDE, CA 92507
FACILITY NAME:THELMA G. SMITH FAMILY CAREFACILITY NUMBER:
366408622
ADMINISTRATOR:JOE ANN PAMILTONFACILITY TYPE:
740
ADDRESS:632 E. MAITLAND AVENUETELEPHONE:
9099862124
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 4CENSUS: 2DATE:
02/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Administrator, Joe Ann PamiltonTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Bernadette Allen conducted and unannounced annual inspection at the facility to ensure compliance with Title 22 Regulations and the Health and Safety laws. Upon arrival, LPA met with the Administrator, Joe Ann Pamilton and toured the inside and outside of the facility. The facility is licensed for four (4) Non-ambulatory elderly residents. There are only two residents in care currently.

LPA observed the facility which is clean and free of odors. There are no bodies of water or firearms present. LPA observed the facility’s license and all other necessary forms posted within the facility. The facility temperature was at 103.2 degrees Fahrenheit.

The residents are treated with dignity. LPA inspected the resident’s rooms and observed the proper lighting and sufficient furniture. The hallways are free of obstruction. There were grab bars near the commodes and in the showers. All rooms were clean, free of clutter and Oder free. LPA inspected the kitchen and dining areas. There was sufficient amount of food; 7 days of non-perishable and 2 days of perishable food on hand. The menu is posted at the kitchen and sharps are in lower cabinet and locked. Last disaster drill was conducted in 12/09/2021 and fire drill conducted on 10/21/2021.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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
RIVERSIDE, CA 92507
FACILITY NAME: THELMA G. SMITH FAMILY CARE
FACILITY NUMBER: 366408622
VISIT DATE: 02/09/2022
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The facility has operable Carbon Monoxide detector and smoke alarms. The outdoor area has shaded space and enough seating for residents.

LPA inspected two residents’ files that contained the Admission Agreement, Needs and Service plan and an updated IPP. The P&I was intact and not co-mingles with facility funds. The medications were reviewed and are given per the physician’s directions. The staff file contained current administrators’ certification and first aid.

No prohibited health conditions were observed. All staff records were current and all training was up to date.

Based on this inspection, no deficiencies were observed at this time in the areas evaluated. An exit interview was conducted with the Administrator. A copy this report was discussed and left with administrator Joe Ann Pamilton

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC809 (FAS) - (06/04)
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