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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601320
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:47:40 PM

Document Has Been Signed on 03/20/2024 04:47 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:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:57 AM
MET WITH:Administrator Roberto RonasTIME COMPLETED:
12:31 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Christian Gutierrez conducted an unannounced Annual Required Visit on 03/20/2024. LPAs were met by Administrator Roberto Ronas and back up Administrator Mona Liza Dela Rosa, and explained the purpose of the visit. 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 8:27 am and was led by Administrator Ronas. The Facility is a single-story dwelling located on a residential street. The facility consists of front yard/back yard, three (3) 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: LPA Ramirez observed front yard to be free of hazards.

Kitchen: LPA Ramirez observed appliances to be clean and 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 kitchen cabinet, to be inaccessible to six (6) out of six (6) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to six (6) out of six (6) clients in care. Signs promoting hand washing were observed in this area. Meal plan was observed in this area for clients in care. First Aid kit was observed and inspected in this area.

Dining Room/Living room: Dining room was observed to contain one table with six (6) chairs. The 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 70 degrees F.

SEE 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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 & M II HOME CARE
FACILITY NUMBER: 198601320
VISIT DATE: 03/20/2024
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Linen Closet/Supply Closet: Supply closet was observed to be inaccessible to clients in care. LPAs observed extra hygiene supplies and client flies in this closet. Linen closet was observed to contain plenty linens, and towels.

Client Rooms 1 - 3: All client bedrooms are shared. LPA Ramirez observed client bedrooms# 2-3 to contain the required linens, furnishings, and lighting. LPAs did not observe a nightstand in shared client bedroom#1 for client#1 (C1). During file review, LPAs discovered C1 has a history of falls and C1’s nightstand was removed as a safety precaution. C1’s file was not observed to contain a physician’s order to remove nightstand or dresser. After discussion with Administrator Ronas, staff placed nightstand back in C1’s room but, it was placed in C1’s closet as to not pose a fall risk to C1. LPA Ramirez will issue Technical Violation for this observation. Auditory device placed on bedroom#1 exit door and was observed to be non-operable. Staff replaced device during visit. LPA Ramirez will issue Technical Violation for this observation. Screen in client bedroom#1 was observed to be in disrepair and stretched. Per Administrator Ronas, staff will replace screen. LPA Ramirez will issue Technical Violation for this observation. Window coverings in bedroom#1 were observed to be dusty and soiled. Staff cleaned window coverings during visit. LPA Ramirez will issue Technical Violation for this observation.

Bathroom 1-2: LPA Ramirez observed nonslip mats in bathroom showers. Water temperature in all client bathrooms were measured within 105 – 120 degrees F. LPA observed signs indicating proper handwashing etiquette.

Backyard: No large bodies of water were observed.

Emergency Drills: Last documented disaster drill was conducted on 01/03/2024 at 7:30 am.

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. Fully charged fire extinguishers were observed throughout the facility. Emergency Disaster Plan.

Personnel Records: Personnel records are maintained at the facility. LPA Ramirez reviewed three (3) personnel records. First Aid Certificate, Fingerprint Clearance/ Exemptions, Personnel Record/Job Application, Health Screening, Employee Rights, TB Test, and Initial/Annual Training Verification. Administrator’s certificate for Roberto Ronas (6045962735) was observed with an expiration date of 02/14/2024. LPA Ramirez observed back up Administrator for Mona Liza Dela Rosa (6010291735) with an expiration date of 02/22/2026.

SEE 809-C

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

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
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 & M II HOME CARE
FACILITY NUMBER: 198601320
VISIT DATE: 03/20/2024
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Client Records: Client files are maintained at the facility. LPA Ramirez reviewed six (6) client records. No deficiency was observed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form.

Infection Control Plan: LPA Ramirez observed and obtained a copy of the facility infection control plan.

No deficiencies were cited today. Four (4) technical violations were cited today. Exit interview was conducted. 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: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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