198600872-11-20-2022-28-AS-VMAO-CLCNRJ-20221120094139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600872
Report Date: 11/20/2022
Date Signed: 11/20/2022 09:41:47 AM

Document Has Been Signed on 11/20/2022 09:41 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 CARE		FACILITY NUMBER:	198600872
ADMINISTRATOR:	AMALIA FERRER		FACILITY TYPE:	735
ADDRESS:	2954 KING STREET		TELEPHONE:	(909) 618-7065
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	6	CENSUS: 6	DATE:	11/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Mona Liza Dela Rosa- LicenseeAdministrator		TIME COMPLETED:	09:50 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of conducting the required annual inspection, using the Infection Control tool to evaluate the facility. LPA Maldonado met with Direct Care Professional (DSP) Vince Panlilio and explained the purpose for the visit. Vince called the administrator/licensee Mona Liza Dela Rosa to notify of the visit. LPA conducted a tour of the physical plant with DSP, observed the food supplies, COVID-19 procedures, and reviewed client and staff files, and client's medications. The facility has an approved mitigation plan on file. Mona Liza arrived shortly after to assist with the visit. The facility is a one-story home located in a residential area. It is licensed to serve (6) developmentally disabled clients, ages 18-59, of which (2) may be non-ambulatory. The home consists of a living room, kitchen, dining room, (3) client bedrooms, (1) staff bedroom, (2) bathrooms, an office, an enclosed shaded patio in the backyard with seating, and an attached garage. LPA observed all client bedrooms to have the required furniture, bedding, linens, sufficient lighting, closet space, and additional storage space. (2) bathrooms were observed to have a shower, toilet, and wash basin. The showers accommodate non-ambulatory clients and have the required grab-bars and non-skid mats. The water temperature was tested and measured between 113F-114F, which is in compliance. The food supplies was observed to be the required 2-day perishables and 7-day non-perishables. A fire extinguisher was observed in the kitchen to have a current inspection and was fully charged. The first aid kit was inspected and had the required items, as well as a current first aid manual. All sharps were observed to be locked and inaccessible in a drawer in the kitchen next to the sink. Cleaning supplies were locked and inaccessible, stored in a cabinet underneath the kitchen sink and in a supply cupboard in the garage. The office is located in the garage, as well as the washer and dryer. All equipment was operational and in good repair. A hallway closet had additional towels and linens for clients. The smoke/carbon monoxide detectors were tested, were interconnected and operational at the time of the visit. (Report continued on LIC809-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A AND M HOME CARE	FACILITY NUMBER: 198600872
	VISIT DATE: 11/20/2022

NARRATIVE

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LPA observed a 30-day supplies of Personal Protective Equipment (PPE) stored in the garage. Additional PPE was observed at the entrance of the facility- the central entry point for screening clients, staff, and visitors. PPE siganage was observed throughout the facility to promote hand washing, cough/sneeze etiquette, and social distancing. All hand washing stations are fully stocked with soap and paper towels.

All client files were reviewed and had updated emergency contact information and health screenings. (2) staff files were reviewed and had Criminal Background Clearances, health screenings, and proof of required annual training and certifications. (2) of (6) client medications were reviewed. They are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, and Health and Safety Codes, no deficiencies were observed or cited during today's visit.

An exit interview was conducted with administrator Mona and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2022

LIC809 (FAS) - (06/04)

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