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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601320
Report Date: 12/29/2022
Date Signed: 12/29/2022 11:35:25 AM

Document Has Been Signed on 12/29/2022 11:35 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
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: 5DATE:
12/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mona De La Rosa - LicenseeTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced case management visit regarding an incident that was not reported to the Community Care Licensing Department in a timely manner. LPA met with Mona De La Rosa (Licensee) and explained the reason for the visit.

On 12/05/2019, C1 was taken to the hospital and was diagnosed with a fractured finger. The facility did not notify or submit an incident report to the Community Care Licensing (CCLD). On 04/01/2020, CCLD was made aware of this incident because a complaint was received.

The deficiency cited is documented on the LIC809D. Exit interview held and a copy of the report and appeal was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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
Document Has Been Signed on 12/29/2022 11:35 AM - It Cannot Be Edited


Created By: Luis Mora On 12/29/2022 at 10:53 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A & M II HOME CARE
FACILITY NUMBER: 198601320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2023
Section Cited
CCR
80061(b)(1)(D)

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80061 Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day...(1) Events reported shall include the following: (D) Any injury to any client which requires medical treatment.
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Facility is to ensure that Title 22 Section 80061 regulations are met at all times. Additionally, an in-service training is to be conducted regarding Title 22 Section 80061 and a training log with staff signature submitted to CCLD by 01/06/2023.
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This requirement is not met as evidenced by:

Based records reviewed, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. C1's fractured finger was not reported to CCLD in a timely manner.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022


LIC809 (FAS) - (06/04)
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