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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603489
Report Date: 09/26/2022
Date Signed: 09/26/2022 03:42:19 PM

Document Has Been Signed on 09/26/2022 03:42 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: 4DATE:
09/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tonya Saunders, administratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Administrator, Tonya Saunders, who assisted with visit. The facility is licensed to serve three (3) non-ambulatory and one (1) ambulatory, ages 18-59. Annual fees are current. LPA discussed with administrator regarding the purpose of today's visit and the inspection.

During the visit, the new inspection tool - infection control domain was used; a tour of the facility was conducted; food supply was reviewed; and medications were reviewed.

This is a single story home which consists of four (4) bedrooms, two (2) bathrooms, living room, dining area, office, kitchen, and a car garage. The facility has two (2) single rooms and one (1) shared room for clients. Facility maintains the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms have beds, dresser, and closet space available. Adequate linen and personal hygiene supply are observed. Lamps/lights for each room are available to ensure the safety and comfort of all persons in the facility. Hot water temperature measured at 118.5 degrees Fahrenheit. Backyard has a covered trash can. Smoke detectors and carbon monoxide detectors are dual and operable.

Medications are centrally stored and locked. Medications are properly logged and current. Hazardous items are locked and inaccessible to clients. Fire extinguisher is fully charged. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils are stored. The front yard is well maintained. No pools or large bodies of water at the facility. Passageways are free of obstruction. Last disaster drill is conducted on 2/11/22. Administrator certificate is current, expires on 11/28/2023.

(-Continued in LIC 809 C-)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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: 09/26/2022
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No deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report was discussed and provided to Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC809 (FAS) - (06/04)
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