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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602563
Report Date: 06/25/2022
Date Signed: 06/25/2022 11:50:56 AM


Document Has Been Signed on 06/25/2022 11:50 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:RAHMAAN HOMEFACILITY NUMBER:
198602563
ADMINISTRATOR:RAHMAAN, ALMAFACILITY TYPE:
735
ADDRESS:1345 ASHPORT STTELEPHONE:
(909) 622-0662
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY:4CENSUS: 3DATE:
06/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Staff #1 (S1)TIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met Staff #1 (S1) and Staff #2 (S2) and explained the reason for the visit. Administrator, Alma Rahmaan was called and notified of the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications and records and observed the food supply. The facility cares for adults with intellectual disabilities and is vendorized by San Gabriel/Pomona Regional Center as a Level 4G facility.

All client bedrooms were toured. All bedrooms are private rooms and have the required bed, bedframe, linen, dresser, light, and closet space. Client's bathroom was toured and the hot water was 111.3 degrees which is within the required 105 - 120 degrees. There were no toxic chemicals accessible to clients. All chemicals are locked in a cabinet in the staff office. The kitchen was inspected. There is sufficient perishable and non-perishable food. There is an additional freezer in the garage. The garage freezer has spilled meat liquid and ants crawling inside. The common areas include the living room and dining area. These areas are clean and have the required furniture. Facility currently has at least a 30-day supply of PPEs. There are no cameras inside or outside the facility. There is a screening station near the front door with PPE's and sanitizer. There is also a sign-in log.

Client files were reviewed to confirm emergency contacts are updated. Staff files were reviewed to confirm health screenings, training and fingerprint clearances. All files were complete. All clients' medications were reviewed. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, the deficiency observed during the visit is documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2022
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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Document Has Been Signed on 06/25/2022 11:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: RAHMAAN HOME

FACILITY NUMBER: 198602563

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made during the tour of the facility, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The garage freezer has spilled meat liquid and ants crawling inside.
POC Due Date: 07/01/2022
Plan of Correction
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Facility will have the freezer cleaned. Facility will submit pictures of the cleaned freezer by 7/1/22.
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2022
LIC809 (FAS) - (06/04)
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