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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602563
Report Date: 08/22/2023
Date Signed: 08/22/2023 05:18:43 PM

Document Has Been Signed on 08/22/2023 05:18 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
GREATER LA AC/SC, 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:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Jamila Rahmaan, StaffTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cynthia Chan and Nune Margaryan conducted the required annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPAs arrived unannounced and the purpose of the visit was explained to Staff, Jamila Rahmaan. The facility is licensed for (4) non-ambulatory adults, ages 18 - 59. The home is vendorized by the San Gabriel/Pomona Regional Center.
The facility consists of 4 Client bedrooms, 1 Administrator's room, 1 Staff office, 2 bathrooms, living room, open kitchen with dining space, and a garage. There are no pools or bodies of water on the premises. The facility is operating within the fire clearance approval. Staff are providing care and supervision to meet the clients' needs and assisting in activities of daily living when needed. There are currently 3 ambulatory clients residing at the home. There are sufficient number of staff to provide care and supervision in all the shifts. The facility staff are wearing gloves while assisting clients. Staff are cleaning and disinfecting during each shift and more often for high touched surfaces. The cleaning supplies are locked in the staff office. Facility has sufficient PPE supplies. There are sufficient food supplies of 2 day perishable and a week of non-perishable items observed. Foods are properly stored in the refrigerator to avoid contamination.

LPA reviewed all 3 Client files. Files have updated emergency contacts, admission agreement, physician's report with TB results, current IPPs, and consent forms. Medications were reviewed for the 3 clients. LPAs observed missing medication but marked on the medication log as taken for Client #1. Per Staff, the medication was discontinued but could not locate the physician's order for it. In addition, during the tour, LPAs observed medications in a cup in Client #1's room.

LPAs did not completed the annual visit today and will return another day to finish.
The deficiencies are issued on the LIC809D. An exit interview was held. A copy of this report, LIC809D, and appeal rights were provided to Staff Jamila.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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 3
Document Has Been Signed on 08/22/2023 05:18 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 08/22/2023 at 03:44 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: RAHMAAN HOME
FACILITY NUMBER: 198602563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(A)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (A) There is written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 3 clients medication log which shows one of Client #1's medication (Divalproex 500mg) was being given but the medication was missing which poses a potential health and safety risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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The licensee shall ensure all discontinued medications have a physician's order in place and submit the discontinuation order for Client #1 to LPA by 8/25/23.

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:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/22/2023 05:18 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 08/22/2023 at 04:09 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: RAHMAAN HOME
FACILITY NUMBER: 198602563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

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 cited regulation in which 1 out of 3 clients' prescribed medications were observed in Client #1's room which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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The licensee shall conduct an in-service training with staff to ensure staff supervises all clients in taking their medications when given to them. This POC is due by 8/23/23.
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:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
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