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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602952
Report Date: 10/09/2023
Date Signed: 10/09/2023 10:55:22 AM

Document Has Been Signed on 10/09/2023 10:55 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A AND M AURORA HOME CAREFACILITY NUMBER:
198602952
ADMINISTRATOR:JOSEPH ESTANISLAOFACILITY TYPE:
735
ADDRESS:555 AUORA DRIVETELEPHONE:
(909) 399-0693
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 4DATE:
10/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Jazzmin Arrant- StaffTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting a Case Management Visit, regarding a request for an exception of furniture use in a client's bedroom. LPA Maldonado met with staff Jazzmin Arrant, and explained the purpose for the visit. Jasmine phoned Administrator, Jerome Estanislao, to inform him of the visit.

Per the facility required annual inspection conducted on 02/04/2023, by LPA Kimberly Ramirez, the facility was cited for C1's bedroom missing a chair, lamp, and dresser. After LPA Maldonado discussed the matter with Jerome, he explained that C1's Individual Program Plan (IPP) indicates that due to C1's self-injurious behavior, the furniture had to be removed. This was a recommendation from C1's physician, and the placement agency was in agreement with the recommendation. He also stated that the supporting documentation was previously submitted to LPA Ramirez, however LPA Maldonado had no knowledge. Jerome provided the following documents to LPA Maldonado on 05/04/2023 for review:
  • Letter of Support from San Gabriel/Pomona Regional Center
  • Letter of support from C1's relative, who is involved in C1's care
  • Recommendation from C1's Primary Care Physician (PCP) to remove furniture
  • Behaviorist Risk Mitigation Plan
  • C1's current IPP dated: 08/04/2022
  • Facesheet
  • Physician's Report
During today's visit, LPA Maldonado conducted a tour of the physical plant with staff Jazzmin, with special focus on Client# 1's (C1) bedroom. It was noted that C1's bedroom did not have a lamp, dresser, or a chair. Per review of C1's PCP's notes from a visit on 2/11/23, it is noted that the PCP has recommended the side tables (drawers), lamp, and chair be removed from C1's room due to safety concerns. After review of all documents, LPA will approve exemption for removal of the furniture from C1's room, and an Exception Letter will follow to be provided to the facility.
Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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