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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603489
Report Date: 08/17/2021
Date Signed: 08/18/2021 12:04:47 PM

Document Has Been Signed on 08/18/2021 12:04 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ABOVE AND BEYOND ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198603489
ADMINISTRATOR:SAUNDERS, TONYAFACILITY TYPE:
735
ADDRESS:430 S. MOUNTAINTELEPHONE:
(951) 323-3852
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 0DATE:
08/17/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tonya Saunders and Lynneshia Williams, LicenseesTIME COMPLETED:
01:00 PM
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 Licensing Program Analyst (LPA) Linda Almaraz conducted an announced Pre-licensing visit and met with Licensee's Lynneshia Williams and Tonya Saunders, and Darlene Setera who assisted with the walk-through. Per Saunders, she will be the primary Administrator and Setera will be a staff member at the facility. A component III was conducted during the visit. There are currently 0 residents living in the facility. The fire clearance has been approved for 3 non-ambulatory and 1 ambulatory bedroom. Bedroom #3 and 4 are cleared for non-ambulatory clients. The physical plant was toured and the following was observed.

This facility is located in a residential neighborhood, single story house, with (4) bedrooms, (2) bathrooms, living room, dining area, kitchen, and a car garage. The facility has (2) single rooms and (1) shared room for clients. Room #4 will be used as an office were client records will be stored. There will be no live-in staff at the facility. Medications will be stored in a locked closet in the living room along with the first aid kit.

Appliances in the kitchen such as dishwasher, microwave, stove and oven were observed to be clean and operational. Sharp objects such as knives are stored in a locked kitchen/dining room closet along with cleaning solutions and chemicals. The washer and dryer are located inside the garage.

Living room has required furniture. There is a fireplace located in the living room which is covered by a screen fence. Dining room has a table and (4) chairs and a bench for a total seating of (6).

Resident rooms were observed to have the required furniture such as bed frames, dressers, chairs and sufficient closet space. Bedrooms also have the required bedding sheets. The bathrooms have operational showers, hand washing sinks and toilets.

The smoke alarms and carbon monoxide detectors were tested and seem to operating properly. The facility has (2) fire extinguishers located in the kitchen/dining room. (Continued on a LIC 809-C)
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ABOVE AND BEYOND ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603489
VISIT DATE: 08/17/2021
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The facility has central air conditioning at a set temperature of 76 degrees. There is sufficient lighting throughout the home. Window and window screens are in good repair. There are no security bars on the windows. There were no obstructions observed on the premises. The home has all the required posters posted. Resident and staff files were not reviewed since there are no residents living in the facility.

The backyard has a shaded patio area with patio furniture. A storage unit is located in the back of the yard with tools that will be locked at all times and inaccessible to clients.

Facility has not met the physical plant requirement per California Code of Regulations Title 22 Division 6 Chapter 8 and has to complete the following within 7 days:

Water temperature needs to be adjusted between 105-120 degrees F
COVID-19 signs and screening log for visitors
PPE supply

Applicant shall submit pictures/video to LPA as proof of correction via email/fax by 8/24/2021.

An exit interview was conducted with Applicant and copy was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC809 (FAS) - (06/04)
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