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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880906
Report Date: 07/24/2024
Date Signed: 07/24/2024 01:04:24 PM

Document Has Been Signed on 07/24/2024 01:04 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/
DIRECTOR:		YOUNES, AMIRRAFACILITY TYPE:
735
ADDRESS:1229 KELLEY AVETELEPHONE:
(650) 656-7941
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 6CENSUS: 6DATE:
07/24/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Areil Galicia and Ahmed QasimTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mary Rico and Serena Ramirez made an unannounced visit to conduct a Health and Safety check of the clients in care at the facility. LPA Rico met with staff Areil Galicia and Licensee Ahmed Qasim explained the reason for the visit.

The Health and Safety check included overall observation of the facility inside, and outside, including food supply, physical plant, and the clients in care.

During the facility, LPA Rico observed the kitchen floor not in repair. The Licensee stated the facility has hired someone to fix the kitchen floor. In addition, LPA observed the client’s bathroom tub dirty.

Based on the observations made during today’s visit, one (2) Type B deficiency were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809 and LIC809D was discussed and provided to Licensee Ahmed Qasim. Along with a copy of appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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
Document Has Been Signed on 07/24/2024 01:04 PM - It Cannot Be Edited


Created By: Mary Rico On 07/24/2024 at 09:07 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: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2024
Section Cited
CCR
8007(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by
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The Administrator has agreed to send LPA Rico proof the kitchen floor has been repair.
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Based on observation the kitchen floor has not been repair the licensee did not comply with the section cited above in which poses health, potential fety or personal rights risk to persons in care.
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POC due date: 7/31/2024
Type B
07/31/2024
Section Cited
CCR80088(e)(3)

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(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary ...
This requirement is not met as evidenced by:
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The licensee has agreed to send LPA proof the bathroom/bathrom tub has been cleaned and create a daily log to ensure the bathroom gets clean.
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Based on observation,the bathroom tub had dirt, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
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POC due date 7/31/2024
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:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
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