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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600872
Report Date: 11/23/2021
Date Signed: 11/29/2021 11:44:58 AM

Document Has Been Signed on 11/29/2021 11:44 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A AND M HOME CAREFACILITY NUMBER:
198600872
ADMINISTRATOR:AMALIA FERRERFACILITY TYPE:
735
ADDRESS:2954 KING STREETTELEPHONE:
(909) 618-7065
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 6CENSUS: 6DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Monaliza Del Rosa-LicenseeTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with DSP Rhodora Cashman explained the reason for the visit. Shortly after, the licensee Monaliza Del Rosa arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures and observed food supply. Facility has submitted a mitigation plan and was approved on 04/11/2021.

The facility is located at the residential neighborhood and it consists of family room, dining area, kitchen, three (3) clients bedrooms, two (2) bathrooms, activity room, one (1) live in staff bedroom and an attached garage with laundry area. All 3 clients bedrooms were toured. Each clients bedroom has two beds, required furniture and linen, sufficient lighting and closet space. All 2 bathrooms were toured and they are clean and maintained in a good condition. The hot water temperature in both bathrooms were tested between 110.6 and 112.3 degrees F. The food in the kitchen cabinet and the refrigerator in the kitchen and garage have sufficient 2 days perishable and 7 days non-perishable food. All the appliances in the kitchen are clean and working properly. The sharp utensils and knives are locked in the kitchen cabinet. All the cleaning products are locked under the sink and they are inaccessible to clients. The common areas such as family room and dining area are clean and have the required furniture. The front and back yard are well maintained. The passageway and exits are free of obstruction. The smoke detectors and carbon monoxide detectors are installed at each bedroom and common area and LPA tested and all are interconnected and working properly.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, social distancing by communal dining and facility is disinfected every clients used. The bathrooms and garage have sufficient soap and paper towels. The PPE supplies are sufficient for more than 30 days.

No deficiencies were found during this visit. Exit interview was conducted with licensee Monaliza Del Rosa and a copy of this report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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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