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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880906
Report Date: 01/26/2023
Date Signed: 01/26/2023 01:15:59 PM

Document Has Been Signed on 01/26/2023 01:15 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A & J RESIDENTIAL CARE FACILITYFACILITY NUMBER:
331880906
ADMINISTRATOR:YOUNES, AMIRRAFACILITY TYPE:
735
ADDRESS:1229 KELLEY AVETELEPHONE:
(650) 656-7941
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 6CENSUS: 7DATE:
01/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Ahmed Oasim- Facility ManagerTIME COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management visit during complaint visit, control number 56-AS-20230124092533. LPA met with Facility Manager Ahmed Qasim and explained the reason for the visit. At the time of the visit, there were seven (7) clients, and two (2) staff present.

During today visit, LPA toured the facility and interviewed clients and staff. During interviews conducted and facility tour, LPA discovered that the facility has seven (7) beds and is providing care to seven (7) clients. LPA explained to Qasim that this is a violation of the approved fire clearance and poses an immediate risk to the clients in care. Qasim stated that they were aware that they were not allowed to have seven (7) clients living at the facility. The facility was issued a deficiency and a civil penalty for violating the fire clearance on 5/10/2022.

Based on observations today, one (1) type A deficiency was cited per Title 22, Division 6, of the California Code of Regulations. Along with a $1000-dollar immediate civil penalty for repeating the violation of the facilities fire clearance.



An exit interview was conducted, and this report(LIC809) was discussed and provided to Facility Manager Ahmed Qasim, along with a copy of LIC809D, LIC421IM, and the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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 01/26/2023 01:16 PM - It Cannot Be Edited


Created By: Ryan Gardner On 01/26/2023 at 11:50 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A & J RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 331880906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2023
Section Cited
CCR
80020(a)

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80020. Fire Clearance. (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
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The licensee has agreed to read regulation 80020 entirely and send LPA self-certified letter that the regulation was read and understood. The licensee has agreed provide care for a maximum of six (6) clients and follow the limitations specified in their license. POC is due by 1/27/2023.
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Based on interview, observation, and record review, the licensee did not comply with the section cited above evidenced by having seven (7) beds and providing care to seven (7) clients facility which is beyond the conditions and limitations specified in their license which poses an immediate health, safety, or personal rights risk to persons in care.
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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:Efren Malagon
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023


LIC809 (FAS) - (06/04)
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