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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880906
Report Date: 06/30/2023
Date Signed: 06/30/2023 02:07:28 PM

Document Has Been Signed on 06/30/2023 02:07 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: 4DATE:
06/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Ahmed QasimTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Victoria Chitgian arrived to conduct an unannounced site visit to the facility for a required annual inspection. Facility is an Adult Residential Facility licensed for six (6) clients, four (4) of status non-ambulatory. Facility currently has a four (4) client census. LPA met with Licensee, Ahmed Qasim at the facility.
LPA conducted a walk-through the facility's interior and exterior. The facility has a charged fire extinguisher, operating fire alarm systems, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. LPA toured the kitchen. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review and included nutritious options. LPA observed the inside of the refrigerators had leaked liquids. Licensee agreed to have staff clean the spilled liquids. Technical Assistance provided. LPA toured the client bedrooms. The client bedrooms had functional lighting and required furniture. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available. The facility has not documented their last emergency and disaster drill on record. Licensee agreed to begin documenting in a log. Technical Violation. Cleaning supplies were stored in the garage locked away. Centrally stored medications were kept in a safe and locked cabinet. Sharps were stored in a secured area. LPA toured the bathrooms and kitchen. Hot water temperature was measured in the bathrooms and was found above the required limits at 135 degrees Fahrenheit. The Licensee adjusted the water heater, but the temperature did not decrease. Technical Violation issued. Licensee agrees to post “Caution- Hot water” signs at all the faucets. The outside of the facility had a shaded area with seating for client comfort. The facility does not have bodies of water. LPA did observe numerous flies flying inside the facility. Technical violation issued.
LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. Client files had the required documentation including an admission's agreement and appraisal/needs & services plans. LPA did not observe physician's reports(LIC 602) filed for four out of four(4/4) clients. Licensee was concerned of the missing LIC 602 in all client files. Licensee stated to immediately contact each of the client’s social workers to obtain copies of the LIC 602's.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2023
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 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/30/2023
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LPA inspected client medications. Medications were dispensed appropriately according to the physician's orders. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care. All required postings were visible in a common area, including the visitation policy. LIC610D was observed to be dated from 2020. Technical assistance issued. Licensee agreed to update the plan annually.

No deficiencies were issued during this visit. Six(6) Technical Violations and one(1) technical assistance were issued.

*See LIC 9102.

An exit interview was conducted where this report (LIC 809) and LIC 9102 was discussed and provided to the Licensee Ahmed Qasim at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC809 (FAS) - (06/04)
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