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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602178
Report Date: 08/19/2022
Date Signed: 08/19/2022 11:03:45 AM

Document Has Been Signed on 08/19/2022 11:03 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:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Emelita Bituin- AdminstratorTIME COMPLETED:
11:10 AM
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Licensing Program Analyst's (LPA) Valeria Maldonado and Kimberly Ramirez conducted an unannounced visit at the facility for a required annual inspection. LPA's Maldonado and Ramirez met with administrator Emelita Bituin and explained the reason of the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, PPE, and food supply. Facility has submitted a mitigation plan and was approved on 05/05/21.

Currently, the facility has no residents residing here. The facility is a one story house located in a residential neighborhood. The home consists of a living room, dining room, family room, kitchen, four bedrooms, two bathrooms, laundry room, and an attached garage. LPA's observed sufficient PPE supplies stored in the garage and around the home. All bedrooms have the required linen and proper furniture. All toilets, hand wash basins, and bath tub/showers are fully stocked, clean, safe, sanitary and in good operation conditions. Bathrooms (RR) have the required grab bars and non skid mats. All sharp knifes and cleaning supplies were locked and inaccessible to persons in care, in the laundry area and in a cabinet under the kitchen sink. LPA's inspected the smoke detector and carbon monoxide and they are all interconnected, operable and in compliance. The hot water measured in RR# 1 at 113.8*F and RR# 2 at 110.8*F. LPA's observed an appropriate food supply of two (2) days perishables and one week (7 days) non-perishables. LPA's observed the front and rear grounds landscaped with ramp leading to the exit and entrance; passageways and outdoor activity area are free of hazards, debris, and obstructions.

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

No deficiencies were observed or cited during today's inspection.

An exit interview was conducted with administrator Emelita Bituin and a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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