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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880906
Report Date: 03/10/2023
Date Signed: 03/10/2023 09:58:32 AM

Document Has Been Signed on 03/10/2023 09:58 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
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: 6DATE:
03/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Analyn Munguia- CaregiverTIME COMPLETED:
10:07 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility to conduct an unannounced case management visit. LPA met with Caregiver Analyn Munguia and explained the reason for the visit. At the time of the visit, there were six (6) clients, and one (1) staff present.

During today’s visit, LPA discovered there is a detached building on the facility property that is being rented out and occupied by two (2) occupants not affiliated with the facility. This poses an immediate health, safety, or personal rights risk to persons in care. The facility property was not licensed to allow outside occupants to rent and occupy on the grounds of the facility.

Based on observations today, one (1) type A deficiency was cited per Title 22, Division 6, of the California Code of Regulations.



An exit interview was conducted, and this report (LIC809) was discussed and provided to Caregiver Analyn Munguia, along with a copy of LIC809D and the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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
Document Has Been Signed on 03/10/2023 09:58 AM - It Cannot Be Edited


Created By: Ryan Gardner On 03/10/2023 at 09:32 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: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2023
Section Cited
CCR
85087(a)(3)(A)

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85087. Buildings and Grounds (a)In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements: (3)No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings.
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The licensee has agreed to read regulation 85087 entirely and send LPA self-certified letter that the regulation was read and understood. The licensee has agreed to vacate the two (2) occupants from the detached building on the property.
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Based on document review, interview, and observation, the licensee did not comply with the section cited above evidenced by renting out the detached building on the property to two (2) occupants which poses an immediate health, safety, or personal rights risk to persons in care.
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The licensee has agreed to send LPA documented proof that the two (2) occupants have been issued a notice to vacate the building. The licensee has agreed to notify licensing when the occupants have moved out of the detached building. POC is due by 3/11/2023.

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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: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


LIC809 (FAS) - (06/04)
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