<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601448
Report Date: 09/20/2022
Date Signed: 09/20/2022 03:59:37 PM

Document Has Been Signed on 09/20/2022 03:59 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 AND M III HOME CAREFACILITY NUMBER:
198601448
ADMINISTRATOR:ROBERTO RONASFACILITY TYPE:
735
ADDRESS:537 CONVERSE AVETELEPHONE:
(909) 618-7065
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 4DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Mona De La Rosa- LicenseeTIME COMPLETED:
04:00 PM
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 required 1 year visit to conduct the annual inspection. LPA Maldonado met with licensee Mona De La Rosa and explained the purpose for the visit.. LPA used the infection control tool to evaluate the facility. During today's visit, LPA toured the physical plant with the licensee. Food and PPE supplies were observed, COVID-19 procedures were reviewed, staff files were checked for criminal background clearance and training, and client medications and files were reviewed for updated emergency information. The facility is licensed to serve six (6) developmentally disabled adults, of which 4 may be non-ambulatory.

The facility is a home located in a residential neighborhood. It consists of 4 client bedrooms, 2 bathrooms, a dining room, a kitchen, a living room, a shaded patio, a locked and inaccessible swimming pool, and an attached garage. LPA observed all client bedrooms to have the required bedding, linens, furniture, and storage space. The bathrooms were observed to have an operating toilet, shower, and wash basin. Both bathrooms accommodate non-ambulatory clients and had the required grab bars. The wash basins were fully stocked with hand soap, paper towels, and hand sanitizer. The water was tested in both bathrooms and measured at 114.2*F in bathroom# 1 and 114*F in bathroom# 2. Sufficient PPE was observed around the facility, readily available for resident/staff/visitor use. Additional PPE was stored in the garage. All the required COVID-19 signage was observed throughout the facility. The food supply was observed in the kitchen to be the required 2-day non-perishables and 7-day non-perishables. The emergency food supplies was also observed in the kitchen pantry. All sharps were observed to be stored and locked in a kitchen drawer next to the kitchen sink, and cleaning supplies and toxins were locked and stored under the kitchen sink and in a locked cabinet in the garage. The kitchen door leading to the attached garage remains locked at all times, inaccessible to clients in care. The washing machine and dryer were observed in the garage, to be operating and in good repair.

(Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2022
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
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 III HOME CARE
FACILITY NUMBER: 198601448
VISIT DATE: 09/20/2022
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
26
27
28
29
30
31
32
LPA reviewed 2 staff files and 4 client files. Staff files were observed to have the required personnel records and client files had updated emergency contact information. Medications for 4 clients in care were reviewed. All medications bubble packs coincided correctly on the Medication Administration Records (MAR) with the date/times administered.

No deficiencies were cited during today's visit.

An exit interview was conducted with licensee Mona De La Rosa and a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2