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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602571
Report Date: 09/11/2023
Date Signed: 09/11/2023 11:21:21 AM

Document Has Been Signed on 09/11/2023 11:21 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 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:
09/11/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Staff, Victor EhichioyaTIME COMPLETED:
11:40 AM
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) Cynthia Chan conducted a subsequent visit to complete the remainder of the annual inspection. LPA arrived unannounced and was allowed entry by staff, Ricardo DeClaro. Administrator, Mona Dela Rosa arrived shortly thereafter to assist with the visit.

During the visit today, LPA finished the following domains using the CARE tools.
Staffing: There is sufficient staffing at the facility. Administrator Certificate for Mona DelaRosa expires on 2/22/24 and the HIV and TB Training certificate was completed on 1/27/22. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed files for 4 Staff. Staff files have current First Aid/CPR certification, Health Screening and Tuberculosis Screening on file. Staff are receiving on-going training.
Client Rights-Information: Client rights are posted and included in Client files. There are no clients using postural supports.
Client Records-Incident Reports: LPA reviewed files for 4 Clients. Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Consent Forms, Individual Program Plan/IPP, and Client Rights were observed.
Incidental Medical Services: No clients have a prohibited health condition. There is 1 client with a restricted health condition plan.
Disaster Preparedness: The facility has the updated Emergency Disaster Plan (LIC610D) in place.
Emergency Intervention: All Staff have CPI training. Staff will utilize mainly redirection.

No deficiencies issued today. Exit interview, appeals rights and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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 1