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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601320
Report Date: 03/04/2022
Date Signed: 03/04/2022 01:42:24 PM

Document Has Been Signed on 03/04/2022 01:42 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A & M II HOME CAREFACILITY NUMBER:
198601320
ADMINISTRATOR:ARIEL P. DELA ROSAFACILITY TYPE:
735
ADDRESS:1476 MURAL DRIVETELEPHONE:
(909) 618-7064
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 6DATE:
03/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:S-1 and Facility AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with S-1 and discussed the purpose of today's visit.
Facility Administrator arrived at approximately 12:10 P.M..

This home consists of (4) bedrooms, (2) bathrooms, kitchen, dinning room, living room, den/family room, laundry room and attached garage. Facility grounds toured.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility. Posted signs also promote hand washing, cough/sneeze etiquette and physical distancing.
  • PPE supplies observed. Per Facility Administrator, there is approximately 60 days worth of PPE supplies readily accessible.
  • Hygiene supplies observed inside the hallway closet. Each client has their own hygiene storage box. The facility has additional hygiene supplies readily available for Clients as well.
  • Hand Sanitizer observed in common areas.
  • Restrooms have hand washing signs, hand soap and hand sanitizer.
  • Sufficient supply of is perishable for 2 days and non-perishable foods for 7 days were observed.
  • Medication reviewed for (3) Clients (Clients #1 through Clients #3).
  • Per Administrator, all (6) Clients are fully vaccinated and have their booster.
  • Per Administrator, all staff are fully vaccinated. (1) staff has their booster pending.
  • Staff responsible for direct care and supervision will continue to wear masks.
  • Clients were be socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Facility Administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
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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