198603489-4-18-2024-28-AS-KRAZ-D4G2GG-20240418172307

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603489
Report Date: 04/18/2024
Date Signed: 04/18/2024 05:23:30 PM

Document Has Been Signed on 04/18/2024 05:23 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:	ABOVE AND BEYOND ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	198603489
ADMINISTRATOR/ DIRECTOR:	SAUNDERS, TONYA		FACILITY TYPE:	735
ADDRESS:	430 S. MOUNTAIN		TELEPHONE:	(951) 323-3852
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY: 4		CENSUS: 4	DATE:	04/18/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:30 AM
MET WITH:	Direct Support Staff Jefferey Asante-Appiah		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LPA Ramirez conducted an unannounced visit on 4/18/2024 to correct previously dated Case Management report 809-D page dated 3/15/24. LPA Ramirez corrected section cited 80072(a)(3) to 80072(a) on 809-D page. No changes to case management findings. CASE MANAGEMENT FINDINGS: LPA Ramirez conducted case management deficiencies visit on 03/15/24 stemming from a subsequent complaint investigation dated 3/15/24. Interviews and records reviewed conducted as a result complaint# 28-AS-20240228090034 revealed on 2/19/24, staff document at 5:54 am, staff heard a loud scream come from C1’s room and saw C1 hitting their roommate (C2). Staff intervened and notified the administrator. This licensing agency was not notified of this incident. On 2/20/24, staff documented in the PM shift that upon staffs’ arrival C1 was observed to me seated in the living room and C2 got up and scratched C1. According to staff notes, C1 received a mark on their face and C1 went to their room to isolate themselves after the incident and stood in their room to watch T.V. and listen to records. Staff did not indicate that first aid was provided after visible mark was seen on C1’s face, and staff did not report this incident to this licensing agency. On 6/22/23, LPA Ramirez conducted a case management deficiencies visit and issued a deficiency for staff not rendering first aid to client in care. Interviews with two (2) out of the two (2) staff on duty confirmed that any injury a client receives is documented when staff render first aid. Licensee cleared deficiency on 6/22/23. LPA Ramirez will issue deficiency for reporting requirements and civil penalties for health-related services on repeat offense. LPA Ramirez reviewed San Gabriel/Pomona Regional Center (SGPRC) Corrective Action Plan (CAP) dated 3/12/24, which revealed S1 texted Administrator Melanie Morris indicating S1 heard C2 scream and found C1 hitting C2 and S1 threatened to call the cops on C1 and made C1 go back to his bed. LPA Ramirez will issue deficiency for personal rights. SEE 809-C for continuation.

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)

Page: 1 of 2

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: ABOVE AND BEYOND ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 198603489
	VISIT DATE: 04/18/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Deficiencies being cited during this visit:

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 C1 and C2 had an altercation which resulted in C1 receiving an injury and failed to report C1 was observed hitting C2.

80072(a)(3) Personal Rights-
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not met as evidenced by: S1 revealed they threatened to use intimidating in C1 by threatening to call the cops on C1 for a behavior C1 exhibited.

80075(a) Health Related Services- *Civil Penalties issued for repeat offense*
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidenced by: Staff did not ensure C1 received first aid and or other medical attention after staff observed C1 receive a scratch on their face as a direct result of C2. Staff did not document they provided first aid.

Deficiencies were observed and civil penalties in the amount of $250 were 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

LIC809 (FAS) - (06/04)

Page: 2 of 2