198602952-2-4-2023-28-AS-KRAZ-CNQRFP-20230204115927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602952
Report Date: 02/04/2023
Date Signed: 02/04/2023 11:59:37 AM

Document Has Been Signed on 02/04/2023 11:59 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 AURORA HOME CARE		FACILITY NUMBER:	198602952
ADMINISTRATOR:	JOSEPH ESTANISLAO		FACILITY TYPE:	735
ADDRESS:	555 AUORA DRIVE		TELEPHONE:	(909) 399-0693
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY: 4		CENSUS: 3	DATE:	02/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Administrator Joseph Jerome Estanislao		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 02/04/2023 at 8:55 am. LPA was met by Licensed Psychiatric Technician (LPT) Sheri Irabor and explained the purpose of the visit. At 9:26 am Administrator Joseph Jerome Estanislao later arrived to lead tour. Facility is licensed to clients 18 – 59 years old. The facility is licensed to served 4 non-Ambulatory clients. Clients at this facility receive services through San Gabriel Valley/Pomona Regional Center. LPA requested and obtained a copy of Personnel Report (LIC 500), Resident Roster (LIC 9020), and copy of Person/Family Centered Planning Individual Program Plan (IPP)

LPA OBSERVATIONS: Tour was given by LPT Irabor at 9:06 am. The facility is located on residential cul da sac. The facility contains front yard, enclosed yard, detached garage, kitchen, dining room/living room, shared client bathroom, linen closet, 4 client bedrooms, and 1 private client bathroom.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7 days of non-perishables. Kitchen sink water temperature was measured at 108.3 degrees F. Signs promoting hand washing and social distancing were observed. Sharps were secured in cabinet and inaccessible to clients.

· Dining Room/Living Room: Dining room area was clean, and LPA observed a table with 7 chairs. Living room area had 2 couches for seating. Signs promoting social distancing and cough/sneeze etiquette were observed throughout this area.

· Linen Closet: Contained plenty of linen and towels.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2023

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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Document Has Been Signed on 02/04/2023 11:59 AM - It Cannot Be Edited

Created By: Kimberly Ramirez On 02/04/2023 at 10:30 AM

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: A AND M AURORA HOME CARE	FACILITY NUMBER: 198602952
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/04/2023

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
1 2 3 4	Based on observation,shared client bathroom sink and private bathroom #4. contained calcuim build and light greenish grime up on both knobs, the licensee did not comply with the section cited above in which 3 out of 3 clients, poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/09/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will clean or replace knobs in shared client bathroom and private client bathroom #4. Picture proof will be submitted to LPA.

Type B

Section Cited

CCR

85088(c)(2)

Fixtures, Furniture, Equipment, and Supplies

(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review,client bedroom #1 was missing chair, dresser and lamp, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/18/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will submit letter to request Exception to remove dresser, chair and lamp from client bedroom #1 due to client using furniture as self harm. Client's clothing and personal belongings is being kept inside closet on a shelf.

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:

Kimberly Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 AURORA HOME CARE	FACILITY NUMBER: 198602952
	VISIT DATE: 02/04/2023

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·Client Rooms 1 - 4: At 9:38 am, LPA observed Client #1 (C1) bedroom to not contain required dresser, chair, and lamp. Per Administrator Estanislao, C1 has a behavioral problem and will hurt himself with furnishings and regional center is aware of the situation and it is documented on C1’s IPP. LPA observed C1’s clothes, shoes and other personal belongings were being kept in a C1’s closet. Closet doors were also removed to protect client according to Administrator Estanislao. Facility did not request an Exception to remove such furnishings. This poses/posed a potential health, safety or personal rights risk to persons in care. Client Bedroom #2, 3 and 4 all contained the required furnishings and linens.

· Bathrooms: Shared Client Bathroom was observed to contain grab bars near toilet and walk in shower. Sink was observed to contain greenish/white calcium build up on sink knobs. Private Client bedroom #4 contained a private bathroom. LPA observed grab bars near toilet and walk in shower. Sink knobs in private bathroom #4 was observed to have greenish/white calcium build up. This poses/posed a potential health, safety or personal rights risk to persons in care.

· Centrally Stored Medications: Located in kitchen was secured and inaccessible to clients. LPA reviewed 2 out of 3 client’s medications. Client #3 (C3) medication was unavailable due to client leaving for the weekend and taking medication.

· Detached Garage: Contained a washer and dryer. LPA observed PPE supplies, emergency water, and emergency food supply.

Administrator certificate was observed for Joseph Jerome Estanislao with an expiration date: 03/10/23. Last fire drill was conducted on 01/08/2023. LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit.

Deficiencies were cited during visit. Exit interview was conducted with Administrator Estanislao and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2023

LIC809 (FAS) - (06/04)

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