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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601320
Report Date: 02/25/2023
Date Signed: 02/25/2023 12:17:01 PM

Document Has Been Signed on 02/25/2023 12:17 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 & 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:
02/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Administrator Sylvia OwnesTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 02/25/2023 at 9:40 am. LPA was met by Staff S1 and explained the purpose of the visit. Administrator Owens arrived later. Facility is licensed to developmentally disabled clients 18 years old to 59 years old. There are six (6) level 4C developmentally disabled clients at this facility and are receiving services from San Gabriel Valley/Pomona Regional Center. LPA requested and obtained a copy of Personnel Report (LIC 500), and Resident Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 9:40 am and was led Staff #1 (S1). The Facility is a single-story dwelling located on a residential street. The facility consists of: front yard/back yard, four (4) shared client bedrooms, two (2) shared client bathrooms, kitchen, living room, dining room, den/tv room, laundry room, staff office, and attached garage.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: At 9:44 am, LPA observed knives and sharps located in a nearby cabinet to be inaccessible to 6 out of 6 clients in care. Kitchen sink cabinet containing cleaning supplies and disinfectants, was observed to be inaccessible to 6 out of 6 clients in care. Signs promoting hand washing were observed throughout this area. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. Kitchen sink water temperature was measured at 114.6 degrees F. Fire extinguisher located nearby was observed to be fully charged.

· Dining room: LPA observed one (1) table and six (6) chairs. LPA observed signs promoting hand washing throughout this area.

· Living room: LPA observed two (2) recliners, one (1) love seat and one (1) couch. Digital thermostat located in nearby hallway was observed to read 68 degrees F. LPA observed signs promoting hand washing.

· Den/Tv room: LPA observed area to be clean and contain two (2) couches. LPA observed two clients watching TV. LPA observed signs promoting hand washing and signs on earthquake/fire drill safety.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2023
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 2
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 & M II HOME CARE
FACILITY NUMBER: 198601320
VISIT DATE: 02/25/2023
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·Shared Client bathrooms# 1&2: Water temperature in client bathroom #1 was measured at 112.8 degrees F. Grab bars and non-slip mats were observed in shower. Grab bars were observed near toilet. LPA observed signs promoting hand washing throughout this area. Client bathroom #2 was observed to be clean and water temperature was measured at 112.2 degrees F which is in the required 105- 120 degrees F.

· Linen closet: Contained extra linen, bedding, towels, extra hygiene products and hand sanitizer.

· Client Bedroom 1-4: All contained the required linen, furnishings and lighting as required. All client bedrooms are shared.

LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. LPA observed an Administrator Certificate (6056743735) for Sylvia Owens with an expiration of 07/23/24. Last fire drill was conducted on 11-30-2022.

No deficiencies are being cited during today’s visit. Exit interview was conducted with Administrator Owens and a copy of this report and appeal rights was provided.

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

DATE: 02/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2023
LIC809 (FAS) - (06/04)
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