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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601772
Report Date: 09/14/2024
Date Signed: 09/14/2024 02:04:23 PM

Document Has Been Signed on 09/14/2024 02:04 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 IV HOME CAREFACILITY NUMBER:
198601772
ADMINISTRATOR/
DIRECTOR:		LADY ROXANNE ARCIBALFACILITY TYPE:
735
ADDRESS:226 E. ANNAPOLIS DRIVETELEPHONE:
(909) 618-7064
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 3DATE:
09/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:22 AM
MET WITH:DSP Nacy AmancioTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met DSP worker Nancy Amancio at approximately 11:20 AM and explained reason for visit. Administrator Roxanne Arciba and Licensee Mona Dela Rosa arrived shortly.Facility is licensed to serve four (4) developmentally disabled adults, ages 18-59. Four can be non-ambulatory. May retain one (1) hospice client. All clients residing at this facility receive services provided by San Gabriel Pomona Regional Center. The facility is in a residential area, and it is a one-story family home. The home consists of a kitchen, living room, dining room, four (4) client bedrooms, (2) client bathrooms, attached garage with storage and laundry area, and a shaded patio with sufficient space for outdoor activities.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke detectors/carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. The facility has one (1) fully charged fire extinguisher which is kept in kitchen. Cleaning supplies and toxic substances are inaccessible to clients in a locked storage in garage as well as within another locked cupboard in kitchen. LPA observed drawer where sharps are kept being unlocked and accessible to client’s deficiency cited. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. During inspection of food supply LPA observed medication not locked in lock box deficiency cited. There is an extra refrigerator in garage with more food. There are no firearms or weapons stored at the facility. Bathrooms were equipped with a toilet, wash basin, and showers. They had the required grab bars and non-skid mats. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. LPA observed stacked boxes of diapers and bags of recyclables in patio area that could pose a potential risk to client’s deficiency cited. SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 09/14/2024 02:04 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 09/14/2024 at 01:25 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: 09/14/2024

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, the licensee did not comply with the section cited above drawer in kitchen where sharps are located was observed to be unlocked, Bathroom # 1 had a bottle of liqued soap under sink unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2024
Plan of Correction
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DSP immediately locked drawer and removed soap during time of visit. Administrator will conduct training with staff and submit a copy of training to LPA by email.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above LPA observed in refrigerator medication not in its required lock box which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2024
Plan of Correction
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DSP immediately locked medication in lock box. Administrator will conduct training with saff and submit a copy of training to LPA by email.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/14/2024 02:04 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 09/14/2024 at 01:25 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: 09/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above LPA observed stacked boxes of diapers and bags of recyclables on porch which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2024
Plan of Correction
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Administrator agrees to move boxes and bags and submit pictures as proof to LPA.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
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 IV HOME CARE
FACILITY NUMBER: 198601772
VISIT DATE: 09/14/2024
NARRATIVE
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Four (4) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Three (3) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in August of 2024. Infectious control plan was reviewed. Three (3) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2024
LIC809 (FAS) - (06/04)
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