198602178-8-6-2023-28-AS-KRAZ-CUFPBE-20230806111013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602178
Report Date: 08/06/2023
Date Signed: 08/06/2023 11:10:20 AM

Document Has Been Signed on 08/06/2023 11:10 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	A & E RESIDENTIAL CARE		FACILITY NUMBER:	198602178
ADMINISTRATOR:	BITUIN, EMELITA		FACILITY TYPE:	740
ADDRESS:	1286 W BASELINE ROAD		TELEPHONE:	(909) 399-5189
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 0	DATE:	08/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:23 AM
MET WITH:	Emelita Bituin		TIME COMPLETED:	11:15 AM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 08/06/2023 at 9:25 am. LPA was met by Administrator Bituin and explained the purpose of the visit. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents and is allowed to care for six (6) bedridden residents. LPA Ramirez requested copies of Personnel Report (LIC 500), Resident Roster (LIC 9020) however, due to the facility currently not having any residents or staff, no copies were provided.

LPA OBSERVATIONS: Tour began at 9:31 am and was led by Administrator Butuin. The facility is a single-story building located in a residential area with three (3) resident bedrooms, one (1) staff bedroom, one (1) staff bathroom, one (1) resident bathroom, kitchen, dining room, living room, front yard, backyard, and attached garage.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to zero (0) out of zero (0) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to zero (0) out of zero (0) residents in care. Kitchen appliances were observed to be clean and in working order. LPA Ramirez observed fully charged fire extinguisher in this area.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed plenty of seating and lighting.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Resident Rooms 1 - 3: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed required auditory devices on exits.

Bathrooms: Signs promoting hand washing were observed. Water temperature in resident bathroom#1 was measured at 114.2 degrees F which is in the required 105 – 120 degrees F. Bathroom was observed to be clean.

SEE 809-C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 & E RESIDENTIAL CARE	FACILITY NUMBER: 198602178
	VISIT DATE: 08/06/2023

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Centrally Stored Medications: N/A due to no residents in the facility at this time.

Backyard: LPA observed plenty of seating and shade. No large bodies of water were observed.

Emergency Drills: N/A due to no residents in the facility at this time.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways. LPA Ramirez observed posted Emergency Disaster Plan.

Staff Personnel Files: N/A due to no residents in the facility at this time.

Resident Files: N/A due to no residents in the facility at this time.

Liability Insurance & Infection Control Plan: Licensee will send Liability Insurance and Infection Control Plan by 8/14/23.

No deficiencies are being cited today. Exit interview was conducted Administrator Butuin and a copy of this report and appeals rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2023

LIC809 (FAS) - (06/04)

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