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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602178
Report Date: 09/10/2021
Date Signed: 09/11/2021 10:09:32 AM

Document Has Been Signed on 09/11/2021 10:09 AM - 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 & E RESIDENTIAL CAREFACILITY NUMBER:
198602178
ADMINISTRATOR:BITUIN, EMELITAFACILITY TYPE:
740
ADDRESS:1286 W BASELINE ROADTELEPHONE:
(909) 399-5189
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 0DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Emelita Bituin TIME COMPLETED:
04:15 PM
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Licensing Program Analysts(LPA) Christine Wong and Alberto Lopez conducted an unannounced annual inspection. LPAs met with administrator Emelita Bitun and explained the reason of the visit. LPA used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures and observed food supply. Facility has submitted a mitigation plan and was approved on 05/05/21

Currently the facility has no resident reside here. The facility is a one story house located at the residential neighborhood. The home consists of living room, dining room, family room, kitchen, four bedrooms and two bathrooms and attached garage. All bedrooms has required linen and proper furniture. All toilets, hand washing and bath tub/shower are clean, safe, sanitary and in good operation condition. Bathroom have required grab bars and non skid mat. All sharp knifes and cleaning supplies were locked and inaccessible to resident . LPA inspected the smoke detector and carbon monoxide and they are all interconnected, operable and in compliance. The hot water measured in the bathroom and kitchen at 120 degree F. LPA observed an appropriate food supply of two (2) days perishables and one week (7 days) non-perishables. LPA observed the front and rear grounds landscaped with ramp leading to the exit and entrance; passageways are free of obstruction. Outdoor activity area is free of visible hazards, debris.

Due to no resident currently reside in the facility, there's no medication to be reviewed during the annual inspection or resident/staff files to be reviewed too.

No deficiencies issued under California Code of Regulations of Regulations Title 22.

Exit interview conducted. A copy of the report was provided to Administrator Emelita Bituin
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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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