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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601448
Report Date: 09/19/2024
Date Signed: 09/19/2024 05:51:54 PM

Document Has Been Signed on 09/19/2024 05:51 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 AND M III HOME CAREFACILITY NUMBER:
198601448
ADMINISTRATOR/
DIRECTOR:		ANA ALARCIOFACILITY TYPE:
735
ADDRESS:537 CONVERSE AVETELEPHONE:
(909) 618-7065
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 4DATE:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:24 AM
MET WITH:Administrator Ana AlarcioTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 09/19/2024. LPA Ramirez was met by Administrator Ana Alarcio and explained the purpose of the visit. The facility is licensed serve six (6) developmentally disabled clients 18-59 years old, of which four (4) may be non-ambulatory. All clients in the facility receive services from San Gabriel/Pomona Regional Center.

LPA OBSERVATIONS: Tour began at 11:17 am. The facility is a single-story dwelling located in a residential area with four (4) client bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, front yard, gated pool and backyard.

Front Yard: LPA Ramirez observed front yard to be free of hazards. Front yard was well maintained.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed a fully charger fire extinguisher nearby.

Dining Room/Living room: Dining room was observed to contain one table with six (6) chairs. Living room was observed to contain plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed signage promoting cough and hand washing etiquette in this area. LPA Ramirez observed nearby thermostat to read 72 degrees F. LPA Ramirez observed one (1) out of the four (4) clients', sitting in living room.

Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

Client Rooms 1 - 4: LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting. All client bedrooms are private. LPA Ramirez observed smoke detector in C1's room to be in disrepair. Staff replaced smoke detector during inspection. LPA Ramirez will issue Technical Violation.

SEE 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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 AND M III HOME CARE
FACILITY NUMBER: 198601448
VISIT DATE: 09/19/2024
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Bathroom 1-2: LPA Ramirez observed grab bars in all showers and non slip mats in all bathrooms showers.

Centrally Stored Medications: LPA Ramirez observed centrally stored medications to be inaccessible to four (4) out of four (4) clients in care. Medications are stored in cabinet near kitchen sink.

Backyard: Gated pool was observed to be inaccessible to clients and area was free of hazards.

Emergency Drills: Proof of last documented emergency drills were conducted on 9/06/24 and 08/01/24.

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.

Staff Personnel Files: Staff files are maintained at the facility. LPA Ramirez reviewed four (4) staff files. LPA Ramirez observed a pending Administrators Certificate for Ana Alarcio. Back up Administrator Mona Liza A Dela Rosa administrator's certificate expires 2/22/26.

Client Files: Four (4) client files were reviewed. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights, and Individual Program Plan were observed.

Infection Control Plan: LPA Ramirez reviewed current infection control plan.

Exit interview was conducted. No deficiencies were cited, one (1) technical violation was observed and noted. A copy of this report, LIC 9102, and appeals rights was provided via email.

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

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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