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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600872
Report Date: 11/25/2023
Date Signed: 11/25/2023 02:38:16 PM

Document Has Been Signed on 11/25/2023 02:38 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
GREATER LA AC/SC, 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:
11/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Vince Gabriel Panlilio-Direct Support StaffTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 11/25/2023. LPA Ramirez was met by Direct Support Staff Vanessa Panlilio and explained the purpose of the visit. The facility is licensed serve six (6) developmentally disabled clients 18-59 years old. The facility is a level III home and may care for two (2) non-ambulatory clients. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020). All clients in the home receive services from San Gabriel/Pomona Regional Center.

LPA OBSERVATIONS: Tour began at 11:05 am. The facility is a single story dwelling located in a residential area with three (3) client bedrooms, one (1) staff bedroom, one (1) activities room, two (2) bathrooms, kitchen, dining room, living room, attached garage, front yard, and backyard.

Front Yard: LPA Ramirez observed front yard to be free of hazards.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to five (5) out of six (6) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet, to be inaccessible to five (5) out of six (6) clients in care. LPA Ramirez observed a fully charger fire extinguisher nearby. Kitchen sink temperature was measured at 124.4 degree F.

Dining Room/Living room: Dining room was observed to contain one table with six (6) chairs. Living room was observed to contain plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed nearby thermostat to read 74 degrees F.

Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

Client Rooms 1 - 3: LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting. All client bedrooms are shared.

See 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2023
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A AND M HOME CARE
FACILITY NUMBER: 198600872
VISIT DATE: 11/25/2023
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Bathroom 1-2: LPA Ramirez observed grab bars in all showers and non slip mats in all bathrooms showers. Bathroom #2 is private and is located in client bedroom #2.

Centrally Stored Medications: LPA Ramirez observed centrally stored medications to be inaccessible to five (5) out of six (6) clients in care. Medications are stored in cabinet near kitchen sink. During medication review, LPA Ramirez observed four (4) over the counter supplements that were prescribed to Client# 2 (C2), did not have prescription label. LPA Ramirez will issue Technical Violation.

Backyard: No large bodies of water were observed and area was free of hazards.

Emergency Drills: Proof of last documented emergency drills were conducted on 05/02/23.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Staff files are maintained at the facility. LPA Ramirez reviewed four (4) staff files. LPA Ramirez observed current Administrators Certificate with an expiration date of 02/22/24 for Mona liza Dela Rosa.

Client Files: Six (6) client files were reviewed. Client #6 (C6) is currently not residing full-time at the facility however, the facility maintains C6 medications and C6 still maintains residency at the facility.

Infection Control Plan: LPA Ramirez reviewed current infection control plan.

Exit interview was conducted. No deficiencies were cited, one (1) technical violation was observed and noted. A copy of this report, LIC 9102, and appeals rights was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2023
LIC809 (FAS) - (06/04)
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