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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880906
Report Date: 05/10/2022
Date Signed: 05/10/2022 05:05:34 PM

Document Has Been Signed on 05/10/2022 05:05 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:House Manager Ahmed QasimTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 05/10/2022 at 1:30 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Staff Jennifer Culadilla and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. House Manager Ahmed Qasim was contacted and arrived at the facility during the visit. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with House Manager Ahmed Qasim. Per documents review, Mitigation Plan was submitted 02/12/2021.

LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility's client bedrooms and bathrooms and observed that both client bathrooms have hand soap and paper towels. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of PPE. LPA Brown went over the various recommended training for facility staff with House Manager Qasim in relation to COVID-19 and House Manager Qasim informed LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

LPA Brown inquired as to if staff have been fit tested for N95 masks, and House Manager Qasim informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive clients, and N95 masks only needing to be worn when a client is COVID-19 positive or under observation while awaiting test results.
**** Continuation in LIC809C ****
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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 9
Document Has Been Signed on 05/10/2022 05:05 PM - It Cannot Be Edited


Created By: Melody Brown On 05/10/2022 at 03:16 PM
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
, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not locking away bleach, ants and roach spray, other cleaning materials located under the sink and two (2) knives found in the kitchen drawer unlocked and making it accesssible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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Licensee stated to train staff on CCR 80087(g) and submit Training Log to LPA Brown by POC due date. Also, Licensee stated to submit Statement of Understanding on CCR 80087(g) and submit to LPA Brown by POC due date.
Type A
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by having eight (8) beds at the 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.
POC Due Date: 05/11/2022
Plan of Correction
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LIcensee immediately pull-out excess beds at the facility. LIcensee stated to submit Statement of Understanding on 80010(a) to LPA Brown by POC due date.
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:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 05/10/2022 05:05 PM - It Cannot Be Edited


Created By: Melody Brown On 05/10/2022 at 03:16 PM
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
, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by having seven (7) clients at the facility thus failing the requirements of their fire clearance capacity of six (6) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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Licensee stated to inform family of Client 1 and relocate Client 1 today and submit proof that Client 1 has been relocated to LPA Brown by POC due date. Also, LIcensee stated to submit Statement of Understanding on CCR 80020(a) to LPA Brown by POC due date.
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by having Staff 4 working at the facility since 05/01/2022 without fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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Licensee stated to not allow Staff 4 to work at the facility until Staff 4 will have criminal background clearance and submit proof to LPA Brown by POC due date. Also, LIcensee stated to submit Statement of Understanding to 80019(e) to LPA Brown by POC due date.
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:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 05/10/2022 05:05 PM - It Cannot Be Edited


Created By: Melody Brown On 05/10/2022 at 03:16 PM
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
, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
85088(c)(1)(B)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s). (B) No adult residential facility shall have more beds for client use than required for the maximum capacity approved by the licensing agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: A & J RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 331880906
VISIT DATE: 05/10/2022
NARRATIVE
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Additionally, all clients have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown will be providing House Manager Qasim with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their clients regularly for any changes in condition and to subsequently notify the clients physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During the tour of the facility, at around 1:45 PM, LPA Brown found bleach, ants and roach spray and other cleaning materials under the sink, not locked and accessible to clients. In addition, LPA Brown also found in the kitchen drawer two (2) knives with blade measurement 7.5 inches and 3.0 inches not locked away and accessible to clients in care. LPA Brown explained to House Manager Qasim that citations will be issued as it poses immediate risks to clients in care. Staff immediately locked away chemicals found under the sink in the garage and locked the knives found in the knives locked drawer

During the visit, LPA Brown requested staff vaccination records and on 05/10/2022 at 02:15 PM, LPA Brown observed all staff and clients have 1st and 2nd dose vaccination record at the facility however, no Booster Vaccination/Exemption record for Staff 3. LPA Brown will be issuing a deficiency for failure to keep records of Worker’s Booster Vaccination/Exemption which can pose potential risk to residents in care.

Also, LPA Brown discovered while interviewing Staff 3 that Staff 4 started working at the facility 05/01/2022 and per documents review, Staff 4 had no fingerprint clearance. LPA Brown informed House Manager Qasim that this poses immediate risk to clients and care and deficiency will be issued together with $500.00 Immediate Civil Penalty. **** Continuation in LIC 809C ****

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
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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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: A & J RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 331880906
VISIT DATE: 05/10/2022
NARRATIVE
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Moreover, during the tour of the facility, LPA Brown discovered that there are seven (7) clients residing at the facility. This facility is licensed for six (6) clients. LPA Brown explained to House Manager Qasim that it is a violation of the approved fire clearance and poses an immediate risk to the clients in care. LPA Brown reviewed the facility reports and it indicated that the facility was cited for the same deficiency last 12/08/2021 thus a civil penalty of $250.00 will be assessed for repeat violation due to the same deficiency issued within twelve (12) months. Also, LPA Brown observed eight (8) beds at the facility, which is over the capacity limitation of six (6). LPA Brown explained to House Manager that citation will be issued.

An exit interview was conducted with House Manager Ahmed Qasim and a copy of this report (LIC809), LIC 809D, LIC421FC, LIC421BG, LIC9102 TA Advisory Notes and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 05/10/2022 05:05 PM - It Cannot Be Edited


Created By: Melody Brown On 05/10/2022 at 04:28 PM
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
, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
121125,120140,120275


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatio,interview and record review, the licensee did not comply with the section cited above by not ensuring the personal rights of persons in care to live in a safe, healthy, comfortable home failed to comply with reporting and personnel requirements and engaged in conduct inimical to the health, welfare and safety of persons in care in that the licensee did not verify workers vaccination, booster or exemption status or unvaccinated workers test result as applicable by maintaining a record as required by State Public Officer Order of December 22, 2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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Licensee stated to submit proof of Booster Vaccination/Exemption of Staff 3 to LPA Brown by POC due date and to update staff vaccination record for all staff at the facility by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


LIC809 (FAS) - (06/04)
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