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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602952
Report Date: 06/07/2024
Date Signed: 06/07/2024 04:32:37 PM

Document Has Been Signed on 06/07/2024 04:32 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 AURORA HOME CAREFACILITY NUMBER:
198602952
ADMINISTRATOR/
DIRECTOR:		JOSEPH ESTANISLAOFACILITY TYPE:
735
ADDRESS:555 AUORA DRIVETELEPHONE:
(909) 399-0693
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 4DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Administrator Joseph EstanislaoTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs) Kimberly Ramirez conducted an unannounced Annual Inspection visit on 06/07/2024. LPA Ramirez were met by Administrator Joseph Estanislao and explained the purpose of the visit. Facility is licensed to clients 18 – 59 years old. The facility is licensed to served 4 non-Ambulatory clients and is approved for delayed egress. Clients at this facility receive services through San Gabriel Valley/Pomona Regional Center. LPA requested and obtained a copy of Personnel Report (LIC 500), and Resident Roster (LIC 9020). LPA Ramirez observed surveillance video in common areas.

The facility is located on residential cul-de-sac. The facility contains front yard, enclosed yard, detached garage, kitchen, dining room/living room, two (2) bathrooms, linen closet, and four (4) client bedrooms.

LPA observations:

· 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.

· Client Rooms 1 - 4: LPA observed client bedrooms 2-4 to contain the required furniture, lighting and linen. Client bedroom#1 has an Exception Granted to remove required bedroom furniture due to this clients’ behavioral needs.

· 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.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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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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: 06/07/2024
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· Centrally Stored Medications: Located in kitchen was secured and inaccessible to clients. LPA reviewed 1 out of 4 client’s medications.

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

· Personnel Records: Personnel records are maintained at the facility. LPA reviewed three (3) personnel records. Administrator certificate was observed for Joseph Jerome Estanislao with an expiration date: 03/10/25. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed.

· Client Records: Client files are maintained at the facility. LPA Ramirez reviewed six (6) client records. No deficiency was observed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form.

· Infection Control Plan: Facility maintains updated infection control plan.

· Emergency Drills: Last fire drill was conducted on 04/01/24 at 3pm and on 01/04/24 at 4pm. LPA observed carbon monoxide in hallways.

· Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit. Fully charged fire extinguishers were observed throughout the facility.

No deficiencies were cited during this inspection. A copy of this report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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