198601448-9-7-2023-28-AS-VMAO-CVFQNU-20230907121942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601448
Report Date: 09/07/2023
Date Signed: 09/07/2023 12:19:50 PM

Document Has Been Signed on 09/07/2023 12:19 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 CARE		FACILITY NUMBER:	198601448
ADMINISTRATOR:	ROBERTO RONAS		FACILITY TYPE:	735
ADDRESS:	537 CONVERSE AVE		TELEPHONE:	(909) 618-7065
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY: 6		CENSUS: 4	DATE:	09/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Mona Dela Cruz- Licensee		TIME COMPLETED:	12:30 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 visit at the facility for the purpose of conducting the required annual inspection, using the Care Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA met with Direct Support Professional, Nizza Ybarra and explained the purpose for the visit. Administrator, Ana Alarcio, and Licensee, Mona Dela Rosa, arrived shortly after to assist with the visit. The facility is licensed to serve (6) developmentally disabled adults, ages 18-59, of which (4) may be non-ambulatory. The facility is a single-story home, located in a residential area. The home consists of (4) client bedrooms, (2) client bathrooms, a kitchen, living room, dining room, attached garage, a fenced pool, and shaded patio with seating area in the backyard. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention. During today's visit, LPA Maldonado obtained a copy of the client and staff roster, and conducted a tour of the physical plant with assistance of DSP, Nizza Ybarra. The following was observed: One central entry point for universal entry screening Mitigation Plan and Infection Control Plan approved and in place Sufficient PPE stored for 30-days and readily available for use, throughout the home and stored in the garage Physical plant inside and outside is clean, sanitary and in good repair All walkways and pathways observed to be free of obstruction/hazards (Report Continued on LIC809-C...)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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
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: 09/07/2023

NARRATIVE

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All client bedrooms had the required furniture and the bedding had the required linens
Additional linens were observed in a linen closet in the hallway, inspected and in good repair.
Cleaning supplies and toxins were observed locked and inaccessible in a cabinet in the garage
Each client bathroom was equipped with a toilet, shower, and wash basin- all operational and in good repair.
Showers had the required grab bars and non-skid mats
The water temperature in both bathrooms was tested and measured at 108.5*F
Sharps and knives were stored inaccessible in a kitchen drawer next to the dishwasher
Food supplies was inspected and observed to have the required 2-day perishables and 7-day non-perishables- food was sufficient for amount of clients in care
Kitchen was observed clean/sanitary, and flatware, utensils, and cups were available and in good repair- sufficient for clients in care
The first aid kit was inspected and had the required items/Current First Aid Manual available
All the required postings were posted throughout the home
The washing machine and dryer were observed in the garage and clean and operational at the time of the visit
The smoke/carbon monoxide detectors were tested and operational during the visit
A fire extinguisher was observed mounted on the kitchen wall, fully charged with a current inspection
Emergency drills are conducted and documented on a quarterly-basis, as required
(4) client files were reviewed and had the required documents
(4) client's Personal and Incidental (P&I) monies was reviewed and observed to be intact and not commingled with facility funds/petty cash.
(4) staff files were reviewed and had the required documents
Administrator Ana Alarcio has a current Administrator Certificate with expiration date: 08/17/2024
(4) client's medications were reviewed and observed to be documented properly and administered as prescribed.
Medications were observed to be centrally stored in the kitchen, locked and inaccessible to clients

Per California Code of Regulations, Title 22, no deficiencies were observed during today's visit.

An exit interview was conducted with Licensee Mona Dela Rosa, and copy of the report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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