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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602571
Report Date: 08/24/2023
Date Signed: 08/24/2023 03:54:11 PM

Document Has Been Signed on 08/24/2023 03:54 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:A AND M ARMOUR HOME CAREFACILITY NUMBER:
198602571
ADMINISTRATOR:SYLVIA OWENSFACILITY TYPE:
735
ADDRESS:2145 ARMOUR STREETTELEPHONE:
(909) 618-7065
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 4CENSUS: 4DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Staff, Victor EhichioyaTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with staff, Victor Ehichioya. The licensee, Mona Dela Rosa, arrived shortly thereafter to assist with the visit. The facility is licensed to serve 4 adults ages 18 through 59, of which 4 may be non-ambulatory. The home is vendorized by the San Gabriel/Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the home.
Infection Control: Staff are cleaning and disinfecting high touched surfaces on each shift. They are using appropriate hand hygiene and wearing gloves when necessary while assisting clients. The facility has submitted the Infection Control Plan.
Physical Plant & Environment Safety: The facility consists of 4 client bedrooms, 2 bathrooms, living room, kitchen, and detached garage. Fire extinguisher is located in the kitchen and was last inspected 1/19/23. There is a carbon monoxide detector located in the living room and smoke detectors in each room. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water was measured within the required range of 105 - 120 degrees F.
Operational Requirements: The fire clearance is approved for (4) non-ambulatory clients. Staff are adhering to operational requirements.
Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Health Related Services: The medications are centrally stored and locked. LPA reviewed medications for all 4 clients and they are being administered as prescribed by the Physician and properly documented.

LPA will continue the remainder of the annual inspection on another date. There are no deficiencies issued today. An exit interview was held and a copy of this report was given to the licensee.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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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