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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880906
Report Date: 08/22/2023
Date Signed: 08/22/2023 12:59:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2023 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230717152314
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: 4DATE:
08/22/2023
UNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Amirra YounesTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff did not provide adequate supervision to a client while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Licensee Amirra Younes and explained the purpose of the visit. The investigation consisted of staff interviews, document reviews, and facility tour.

For allegation, Staff did not provide adequate supervision to a client while in care.

During staff interviews, S1 admitted to LPA Rico that they were sleeping inside their car when C3 (AWOL) had left the facility without supervision. S1 informed LPA that C3 was accompanied by Corona Police, upon their arrival there were no staff on the premises.

During document review, C3 admission agreement states client requires supervision due to confusion, forgetfulness and wandering.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20230717152314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 331880906
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2023
Section Cited
CCR
85065.6(c)
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85065.6(c) Night Supervision
(c) In facilities providing care and supervision for 15 or fewer clients, there shall be at least one person on call on the premises.
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Licensee stated they would train their staff to provide night supervision for clients.
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Based on interview and record review, the licensee did not ensure night supervision for clients,which poses an immedtiate Health, Safety or Personal Rights risk to resident in care
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POC due date 8/23/2023
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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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230717152314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 331880906
VISIT DATE: 08/22/2023
NARRATIVE
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Based on the evidence gathered during today’s investigation, the one (1) allegation listed above is deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met.

During today’s visit, one (1) deficiency were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to Licensee Amirra Younes, along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3