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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601448
Report Date: 09/15/2025
Date Signed: 09/15/2025 02:39:26 PM

Document Has Been Signed on 09/15/2025 02:39 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
MONTEREY PARK ASC, 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:
09/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:54 AM
MET WITH:Licensee Mona Dela Rosa TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Gabriela Castro conducted an unannounced Annual Required Visit on 09/15/2025. LPAs was met by Direct Support Personnel (DSP) Christina Nario and explained the purpose of the visit. Licensee Mona DelaRosa arrived shortly after to assist. 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 utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control- Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Physical Plant & Environmental Safety- Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be accessible to one (1) out of four (4) clients in care. Kitchen knives were accessible in the kitchen cabinet drawer. The locking mechanism was observed to be broken. Staff immediately removed knives and sharps in this cabinet and placed them in an inaccessible cabinet. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) client rooms. Four (4) out of four (4) the client bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be 127.3 F degrees.

SEE 809-C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A AND M III HOME CARE
FACILITY NUMBER: 198601448
VISIT DATE: 09/15/2025
NARRATIVE
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Operational Requirements- Fire clearance is approved for six (6) developmentally disabled clients 18-59 years old, of which four (4) may be non-ambulatory. Staff provides care and needs according to the clients’ needs. Outdoor space with plenty of shade was observed.

Staffing- Administrator Certificate for Ana Alarcio with an expiration date of 08/17/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. One (1) direct support staff are awake and on duty from at least 10pm to 6am to provide nighttime supervision, per Licensee DelaRosa.

Personnel Records-Training- Staff files are maintained at the facility. LPA Ramirez observed training, CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel record reviewed. The administrator’s training on HIV and TB was reviewed and completed.

Clients Rights-Information- The facility has internet services and can provide internet access on a phone for clients to use.

Food Service- LPA Ramirez observed a sufficient supply of nonperishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C).

Client Records-Incident Reports- LPA Ramirez observed original admissions agreements in client records. LPA Ramirez observed Individual Program Plan (IPP), Needs and Services and Functional Capabilities Assessment. LPA Ramirez observed current medication record orders and incident reports regarding clients’ health and safety.

Health Related Services- The medications are centrally stored in the medication cabinet and in bubble packs and/or original containers. The facility provides incidental medical services.

Incidental Medical Services- There are zero (0) clients currently with Restricted Health conditions residing at the facility.

SEE 809-C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2025 02:39 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/15/2025 at 02:01 PM
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 AND M III HOME CARE
FACILITY NUMBER: 198601448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, kitchen knives were accessible in the kitchen cabinet drawer. The locking mechanism was observed to be broken, the licensee did not comply with the section cited above in 4 out of 4 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2025
Plan of Correction
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Staff repaired locking mechanism and LPAs verified the knives were inaccessible. This clears 24 hour correction.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, water temperatures in all grooming and bathing areas were measured to be 127.3 F degrees, the licensee did not comply with the section cited above in 4 out of 4 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2025
Plan of Correction
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Staff adjusted water tempertaure within regulation. LPAs verified water temp was within 105 F to 120 F degrees. This clears 24hr correction. Facility will develop and maintain a water log for the next 7 business days and record water temp reading for the AM and PM shifts. Water log must be emailed to LPA Ramirez by 09/23/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A AND M III HOME CARE
FACILITY NUMBER: 198601448
VISIT DATE: 09/15/2025
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Disaster Preparedness- The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. The last documented emergency drills were conducted on 07/02/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed an emergency food supply located in bins by patio area.

Emergency Intervention- Per Licensee DelaRosa, the facility does not use manual restraints or seclusion rooms. Staff will use redirection when clients become agitated and contact the client’s doctor for further instructions.

Two (2) deficiencies were cited during this annual inspection. Exit interview conducted. A copy of this report, 809-D, LIC 9102, and appeals rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC809 (FAS) - (06/04)
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