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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603489
Report Date: 04/18/2024
Date Signed: 04/18/2024 05:21:22 PM

Document Has Been Signed on 04/18/2024 05:21 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:ABOVE AND BEYOND ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198603489
ADMINISTRATOR/
DIRECTOR:		SAUNDERS, TONYAFACILITY TYPE:
735
ADDRESS:430 S. MOUNTAINTELEPHONE:
(951) 323-3852
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 3DATE:
04/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:54 PM
MET WITH:Direct Support Staff Jefferey Asante-AppiahTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced visit on 4/18/24, stemming from previous case management visit on 3/15/24.
Case Management Findings:
It was revealed that Client#1 (C1) was taken to the hospital in 4/6/2024 via 911 due to C1 injuring themselves and causing property damage. As of 4/18/24, C1 has not retuned to the facility and remains in the hospital. This licensing agency did not receive a written report within 7 days from date of occurrence of 4/6/24. LPA Ramirez will issue deficiency based on record review and staff interviews. This facility was previous cited on 3/15/24 for noncompliance of Title 22- 80061(b)(1)(E)-Reporting Requirements. Therefore, LPA Ramirez will issue an immediate civil penalty in the amount of $250.

Deficiency observed:
80061(b)(1)(E) Reporting Requirement-
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. 1. For community care facilities that serve children, a pregnancy or termination of a pregnancy does not, in and of itself, constitute an unusual incident unless it meets the criteria specified for mandated reporting in Penal Code section 11166 (a).
This requirement was not met as evidenced by: Licensee failed to report to this licensing agency that C1 was taken to the hospital due to self injury and property damage.

Deficiency was observed and an immediate civil penalty in the amount of $250 was assessed. A copy of this report, LIC 421 and appeals rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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Document Has Been Signed on 04/18/2024 05:21 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 04/18/2024 at 12:58 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: ABOVE AND BEYOND ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198603489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2024
Section Cited
CCR
80061(b)(1)(E)

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80061 Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours.
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(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. 1. For community care facilities that serve children, a pregnancy or termination of a pregnancy does not,
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In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.(1) Events reported shall include the following:
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 in and of itself, constitute an unusual incident unless it meets the criteria specified for mandated reporting in Penal Code section 11166 (a). This requirement was not: Licensee will certify to comply with this regulation and provide re-training by 4/25/24.

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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: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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