<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602571
Report Date: 07/25/2022
Date Signed: 07/25/2022 03:09:08 PM

Document Has Been Signed on 07/25/2022 03:09 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A AND M ARMOUR HOME CAREFACILITY NUMBER:
198602571
ADMINISTRATOR:BRITTANY JONESFACILITY TYPE:
735
ADDRESS:2145 ARMOUR STREETTELEPHONE:
(909) 618-7065
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 4CENSUS: 4DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Mona Dela Rosa, AdministratorTIME COMPLETED:
03:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Staff #1 (S1) and explained the reason for the visit. Administrator, Mona Dela Rosa was called and arrived a short time later. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications and records, staff records and observed the food supply. The facility cares for intellectually disabled adults and is vendorized by San Gabriel/Pomona Regional Center.

All client bedrooms were toured. Bedrooms have the required bed, bedframe, linen, dresser, light, and closet space. Client bathrooms were toured and the hot water was 108.4 degrees which is within the required 105 - 120 degrees. There were no toxic chemicals accessible to clients. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and are operating properly. There is a second freezer in the garage with additional food. 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 the facility. There is a screening station at the entrance of the facility to screen visitors. Staff document client temperatures and symptoms daily.

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

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022
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 1