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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600872
Report Date: 10/25/2024
Date Signed: 10/25/2024 03:44:47 PM

Document Has Been Signed on 10/25/2024 03:44 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/
DIRECTOR:		AMALIA FERRERFACILITY TYPE:
735
ADDRESS:2954 KING STREETTELEPHONE:
(909) 618-7065
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 6CENSUS: 5DATE:
10/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:08 PM
MET WITH:Administrator Lady Roxanne ArcibalTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by Direct Support Staff. Administrator Lady Roxanne Arcibal, arrived shortly after to assist with tour. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single story dwelling.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to clients, were observed to be inaccessible to clients. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) client rooms. All client bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed shower in bathroom #1 to be wheelchair accessible.

Food Service: LPA Ramirez observed sufficient supply of nonperishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C).

Infection Control: Staff is using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.



Operational Requirements: 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.

SEE 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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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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: 10/25/2024
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Emergency Intervention: Facility staff are trained in Crisis Prevention & Intervention Training. Facility staff do not foresee the future use manual restraints or have a seclusion room in the facility.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drill was conducted on 08/01/2024 at 7 am. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in garage.

Health Related Services/Incidental Medical Services: The medications are centrally stored and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services.

Staffing: Administrator Certificate for Mona Dela Rosa and expires 02/22/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.


Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for three (3) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed.

Client Records/Incident Reports: LPA reviewed client records for five (5) clients in care. Client records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Individual Program Plan (IPP), and Resident Rights were observed. All clients receive services from San Gabriel/Pomona Regional Center.



No deficiencies were observed during visit. Exit interview conducted. A copy of this report was provided
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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