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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601772
Report Date: 10/14/2022
Date Signed: 10/14/2022 12:35:42 PM

Document Has Been Signed on 10/14/2022 12:35 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 IV HOME CAREFACILITY NUMBER:
198601772
ADMINISTRATOR:ROBERTO RONASFACILITY TYPE:
735
ADDRESS:226 E. ANNAPOLIS DRIVETELEPHONE:
(909) 618-7064
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 4DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Ana Alarcio/S-1 and Mona Dela RosaTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Ana Alarcio/S-1 and explained the purpose of today's visit. Mona Dela Rosa arrived at approximately 9:30 A.M.. Per Ms. Dela Rosa, a infection control plan has been submitted to CDSS. The infection control plan was readily available at this facility.

LPA conducted a facility tour. This single-story home contains four (4) client bedrooms, two (2) bathrooms, living room, kitchen and dining area. San Gabriel Pomona Regional Center provides case management services for all (4) clients residing at this facility.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed throughout the facility. Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed. Additional supplies are stored inside the hallway closet.
  • Hygiene and incontinence supplies observed. Additional supplies are stored inside the garage.
  • Restrooms have hand soap, hand sanitizer and paper towels. Hand washing signs were observed posted in both bathrooms.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Emergency food supply stored inside the garage.
  • Medication reviewed for (4) Clients (Client #1 through Client #4).
  • Per S-1, all (4) clients are fully vaccinated including the booster vaccines.
  • Per S-1, all staff are fully vaccinated including the booster vaccines.
  • Per S-1, all (4) clients have their flu vaccine pending.
  • Clients were be socially distanced according to local public health guidelines.
  • Staff responsible for direct care and supervision wear masks.
Exit interview conducted, a copy of this report and Appeal Rights were provided to Ana Alarcio/S-1
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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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