Community Care Licensing

Document Has Been Signed on 09/30/2024 04:09 PM - It Cannot Be Edited

FACILITY NAME:	A AND M III HOME CARE		FACILITY NUMBER:	198601448
ADMINISTRATOR/ DIRECTOR:	ANA ALARCIO		FACILITY TYPE:	735
ADDRESS:	537 CONVERSE AVE		TELEPHONE:	(909) 618-7065
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY: 6		CENSUS: 4	DATE:	09/30/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:58 PM
MET WITH:	Ana Alarcio, Administrator and Mona De La Rosa, Licensee		TIME VISIT/ INSPECTION COMPLETED:	04:34 PM

SUPERVISORS NAME: Lisa Hicks LICENSING EVALUATOR NAME: Alberto Lopez LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024

Link to Parent Document Below:

FACILITY NAME: A AND M III HOME CARE	FACILITY NUMBER: 198601448
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/04/2024 Section Cited CCR 85064(j)(2)	1 2 3 4 5 6 7	85064(j)(2) Administrator Qualifications and Duties (j) The administrator shall perform the following duties: (2) Development of an administrative plan and procedures to define lines of responsibility, workloads, and staff supervision. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will train all staff and clearly define their lines of responsibilities and send POC by due date.
	8 9 10 11 12 13 14	Licensee did not define lines of responsibilities to 1:1 responsible for supervision of C1 during the NOC shift on 04/22/2024	8 9 10 11 12 13 14
Type B 10/04/2024 Section Cited CCR1507(c)(1)(A)	1 2 3 4 5 6 7	(1) For regional center clients the following shall apply: (A) An individualized health care plan, which may be part of a client's individual program plan, shall be prepared for each client by a health care team that shall include the client or his or her designee if the client is not able to participate in planning his or her health care, the client's primary care physician or nurse practitioner or other health care professional designated by the physician or nurse practitioner, the licensee or licensee's designee, any involved social worker or regional center worker, and any health care professional designated to monitor the client's individualized health care plan. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	License will write a letter to CCL explaining what steps will be taken to insure the this deficiencies does not occur again and send to LPA by POC which is 10/04/2024
	8 9 10 11 12 13 14	Based on record review, the licensee did not comply with the section cited above. C1 did not have required documentation (purpose of 1:1) on current IPP or behaviorist report which poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Lisa Hicks LICENSING EVALUATOR NAME: Alberto Lopez LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024

Link to Parent Document Below:

FACILITY NAME: A AND M III HOME CARE	FACILITY NUMBER: 198601448
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/04/2024 Section Cited CCR 80069(b)	1 2 3 4 5 6 7	(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will write a letter to CCL and state that she read and understands the section 80069(b) and how it will be prevented from happening again by POC date, Licensee will send letter to LPA by due date of 10/04/24.
	8 9 10 11 12 13 14	Based on record review, LPA observed that C1 (Client #1) did not on have a care plan on file which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

SUPERVISOR'S NAME: Lisa Hicks LICENSING EVALUATOR NAME: Alberto Lopez LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024