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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602952
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:23:29 PM

Document Has Been Signed on 01/11/2024 03:23 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:JOSEPH ESTANISLAOFACILITY TYPE:
735
ADDRESS:555 AUORA DRIVETELEPHONE:
(909) 399-0693
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 4DATE:
01/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Joseph EstanisaloTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 01/11/2024 at 10:00 am, stemming from initial complaint investigation conducted on 01/11/2024. LPA Ramirez was greeted by Administrator Joseph Estanislao.

Case Management-Deficiencies findings:

· During facility tour at 10:07am, LPA Ramirez observed two (2) kitchen cabinets that contained knives, sharps, and disinfectants, to be accessible to clients in care. LPA Ramirez observed key in locks attached to lanyard. During tour, staff were observed assisting clients in care in different sections of the facility and keys remained in lock and accessible to clients. LPA Ramirez instructed staff to remove key and secure sharps and disinfectants. Per staff, lunch was in the process of being prepared at 11am. LPA Ramirez will issue deficiency.

· At 10:05am LPA Ramirez observed discarded mattress and plastic bags (some torn and half ways open) filled with empty plastic bottles, scattered near and around discarded mattress. LPA Ramirez will issue deficiency.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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 3
Document Has Been Signed on 01/11/2024 03:23 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 01/11/2024 at 02:44 PM
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: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2024
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement was not met as evidence by:
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Facility staff will be re-trained on this regulation and will send proof of re-training by 01/22/2024 via email. Staff removed key from locks while LPA was present. This will satisfy 24hr correction.
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LPA observed 2 cabinets with key in locks and accessible to clients in care.
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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: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/11/2024 03:23 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 01/11/2024 at 02:50 PM
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: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2024
Section Cited
CCR
80087(c)

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80087 Buildings and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
This requirement was not me as evidence by:
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Facility will remove discarded mattress and clean up empty plastic bottles. Picture proof required by 01/22/2024.
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LPA observed discarded mattress and scattered empty plastic bottles on side of facility passageway.
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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: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024


LIC809 (FAS) - (06/04)
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