306005471-10-11-2022-22-AS-ETAA-CK4P4R-20221011105933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005471
Report Date: 10/11/2022
Date Signed: 10/11/2022 10:59:43 AM

Document Has Been Signed on 10/11/2022 10:59 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	A&M ASSISTED LIVING		FACILITY NUMBER:	306005471
ADMINISTRATOR:	NATALIA SURGENT		FACILITY TYPE:	740
ADDRESS:	4461 PALOMA LANE		TELEPHONE:	(714) 366-1858
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 5	DATE:	10/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Cosmin Surgent		TIME COMPLETED:	11:15 AM

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	Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff and stated the purpose of this visit. Administrator was not able to make the inspection. The facility is a single-level structure and licensed for five non-ambulatory with a hospice waiver for three. One may be bedridden. This facility is a Residential Care Facility for the Elderly. At about 9:25 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 5 residents in care and staff members on duty. LPA toured the interior and exterior portions of the facility. There were 5 resident rooms 1 of which was a shared room. There was also a staff room which inaccessible to residents. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 111.3 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Backyard also had different fruit trees in good condition. Facility offers a 2-car garage which is kept locked and used for storage, contained emergency food, refrigerator and a car. Laundry room was locked and inaccessible to residents and contained an operational washer/dryer. Kitchen was in good repair. LPA noticed a knife in an open drawer. LPA interviewed staff and they stated, “I use it to cut saran wrap.” Staff immediately removed it from residents in care. Medications were kept locked separately. LPA spoke with Administrator over the phone and informed them of annual late fee. Administrator paid annual fee and was provided with a confirmation number.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: A&M ASSISTED LIVING	FACILITY NUMBER: 306005471
	VISIT DATE: 10/11/2022

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LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency Disaster Plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. One advisory was issued today.

LPA Tapia conducted an exit interview with staff and a copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC809 (FAS) - (06/04)

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