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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601772
Report Date: 10/25/2021
Date Signed: 10/25/2021 12:17:13 PM

Document Has Been Signed on 10/25/2021 12:17 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 IV HOME CAREFACILITY NUMBER:
198601772
ADMINISTRATOR:ARIEL P. DELA ROSAFACILITY TYPE:
735
ADDRESS:226 E. ANNAPOLIS DRIVETELEPHONE:
(909) 618-7064
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 3DATE:
10/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Roberto Ronas and Monaliza de la RosaTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Spencer met with licensee Monaliza de la Rosa and assistant administrator Roberto Ronas and discussed the purpose of today's visit. This single-story home contains four (4) client bedrooms, two (2) bathrooms, a living room, kitchen, dining area, and backyard.
The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, screening log, and hand-sanitizer. COVID-19 signage was placed in several areas and temperature logs were maintained.
  • Facility maintained a 30-day supply of PPE.
  • There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods.
  • Sharps were observed to be accessible. At 10:09 a.m., LPA observed that the knife drawer in the kitchen was unlocked. The staff immediately locked it.
  • All areas were observed to be clean and in good repair.
  • Each room contained required furniture: bed, dresser or drawer space, night stand, lamp and chair.
  • All beds contained the required linen including mattress cover, fitted sheet, flat sheet, blanket, and comforter.
  • Bathrooms contained supplies including liquid soap, toilet paper, and paper towels.
  • Medications were locked, centrally stored, and given as prescribed. 30-day supply was maintained.
  • Staff wore face masks consistently throughout the shift.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • A fire extinguisher was observed to be fully charged and last serviced January 2021.
  • All client files were inspected: emergency contact information and physician's reports were up-to-date.
  • Four (4) staff files were inspected and contained required health screenings, criminal record clearances, first aid/CPR and training certificates.
  • An updated administrator certificate was observed and expires on 1/10/23.
Pursuant to Title 22, a deficiency was cited on attached 809D. An exit interview was conducted and a copy of this report and Appeal Rights were provided to the licensee.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2021
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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Document Has Been Signed on 10/25/2021 12:17 PM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 10/25/2021 at 12:04 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 IV HOME CARE
FACILITY NUMBER: 198601772

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)

80087(g) Buildings and Grounds. 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 at 10:09 a.m., the licensee did not comply with the section cited above due to the sharps drawer not being locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2021
Plan of Correction
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The staff immediately locked the drawer making the sharps inaccessible. This deficiency was cleared prior to the end of the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2021


LIC809 (FAS) - (06/04)
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