<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880906
Report Date: 05/09/2025
Date Signed: 05/09/2025 03:43:32 PM

Document Has Been Signed on 05/09/2025 03:43 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: 5DATE:
05/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Substitute Administrator- Amirr Younes TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with staff Maribel Garcia and was granted entry to the facility. Licensed capacity is (6) current census (5). LPA was accompanied by to substitute administrator Amirr Younes to conduct a general overall inspection and Licensee Ahmed Oasim was contacted and informed about today's visit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). The facility is maintained at a comfortable temperature. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated space for client/staff files. Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Deficiencies for facility tour: LPA observed the dining area, living room, C3 bedroom and bathroom light bulbs to be out of service. Client’s bathroom cabin had dirt inside, and wall frames located by the dining area had dirt and dust. LPA observed rat droppings and one alive cockroach. In addition, two sections of the stove were not working. S1 stated they use a fire match to turn on the right side of the stove. During outside facility tour, LPA Rico observed the facility had trash bags full of client’s belongings blocking the pathways. Furthermore, LPA Rico observed the dry storage food pantry had a lock.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Mary Rico
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2025
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 11
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 11
Document Has Been Signed on 05/09/2025 03:43 PM - It Cannot Be Edited


Created By: Mary Rico On 05/09/2025 at 02:00 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85095.5(a)(2)(B)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (B) Walls and window coverings in client care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled. 

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above by having the walls by the dining area with dirt and dust which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2025
Plan of Correction
1
2
3
4
The Administrator Amirr Younes stated they will have staff clean the walls and will send proof to LPA Rico
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(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:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above by having the dining floor dirty, and the right section of the stove out of service and which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2025
Plan of Correction
1
2
3
4
The Administrator Amirr Younes stated they will have someone repair the stove and will have an in-service training for all staff. The Administrator will send proof to LPA Rico.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 05/09/2025 03:43 PM - It Cannot Be Edited


Created By: Mary Rico On 05/09/2025 at 02:00 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)(1)
Building and Grounds
(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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, by having rat dropping by the dining area and on alive crockroach which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2025
Plan of Correction
1
2
3
4
The Administrator stated they will have pest control company conduct an inspection and will send a copy of innvoice to LPA. In addition, the staff will remove the rat dropping and sanitize all areas.
Type A
Section Cited
CCR
80025(b)
Bonding
(b) All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having a surety bond which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2025
Plan of Correction
1
2
3
4
The Administrator will send a copy of surety bond to LPA Rico.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 05/09/2025 03:43 PM - It Cannot Be Edited


Created By: Mary Rico On 05/09/2025 at 02:00 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having accurate records for C3 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2025
Plan of Correction
1
2
3
4
The Administrator stated they will send all accurate records of C3 cash resources that includes ROG services documents.
Type A
Section Cited
CCR
80026(h)(1)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review , the licensee did not comply with the section cited above by not having C3 chronological order receipts for year 2024 and 2025 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
1
2
3
4
The Administrator stated they will send C3 chronological receipts for the year 2024 and 2025 to LPA Rico, along with C2 cash resources and current ledger account.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 05/09/2025 03:43 PM - It Cannot Be Edited


Created By: Mary Rico On 05/09/2025 at 02:00 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80026(h)(1)(A)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order. (A) Receipts for cash provided to any client from his/her account(s) shall include the client's full signature or mark, or authorized representative's full signature or mark, and a statement acknowledging receipt of the amount and date received, as follows: "(full signature of client) accepts (dollar amount) (amount written cursive), this date (date), from (payor)."

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having authorized representative full signature and statement of ackowledement receipt which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2025
Plan of Correction
1
2
3
4
The Administrator stated they will send all authorized representative's full signature or mark, and a statement acknowledging receipt of the amount and date received to LPA Rico

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 05/09/2025 03:43 PM - It Cannot Be Edited


Created By: Mary Rico On 05/09/2025 at 02:00 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
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: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review , the licensee did not comply with the section cited above by not having S2 criminal clearance transfer to this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2025
Plan of Correction
1
2
3
4
The Administrator stated they will submit the transfer request for S2 and send proof to LPA Rico.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 05/09/2025 03:43 PM - It Cannot Be Edited


Created By: Mary Rico On 05/09/2025 at 02:00 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(b)(1)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following: (1) Protective devices including but not limited to nonslip material on rugs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having a towel used as nonslip rug which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2025
Plan of Correction
1
2
3
4
Administrator removed the towel and will send proof they have purchase a nonslip rug.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above by having trash bags blocking outdoor passegeways which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2025
Plan of Correction
1
2
3
4
The Administrator stated they will clean the outdoor passageways and send proof to LPA Rico.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 05/09/2025 03:43 PM - It Cannot Be Edited


Created By: Mary Rico On 05/09/2025 at 02:00 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not having dining area, living room area, bathroom and C3 light bulb replace which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2025
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having Administrator HIV Training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2025
Plan of Correction
1
2
3
4
Administrator stated they will submit their HIV training.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
Page: 9 of 11
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: 05/09/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Record Review: LPA also reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Deficiencies for record: LPA Rico observed the Administrator Amirra Younes had incomplete file such as their CPR, HIV Certificate and training's for 2025. In addition, S2 does not have a file at the facility and criminal clearance is not associated to this facility. Furthermore, C3 cash resources documents were incomplete, incomplete money and facility did not surety bond. During medication audit, LPA Rico observed C2, and C3 PRN medication did not have the result and reason documented.

Based on the observations made during today’s visit, Type A and Type B deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) (LIC809D)(LIC421BG) was discussed and provided to Administrator Amirr Younes. Along with the appeal rights

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Mary Rico
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 05/09/2025 03:43 PM - It Cannot Be Edited


Created By: Mary Rico On 05/09/2025 at 02:54 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(c)
Health- Related Services 8075(b)(5)(c) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by 2 out of the 6 clients PRN medication did not have client's response which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2025
Plan of Correction
1
2
3
4
The Administrator stated an in-service training will be conducted and a copy will be provided to LPA Rico.
Type A
Section Cited
CCR
80066(a)

Personnel Records (e) All personel records shall be maintained at the facility site
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review) the licensee did not comply with the section cited above in S2 file not at the facility and Administrator Amirra Younes incomplete which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2025
Plan of Correction
1
2
3
4
The Administrator will send a copy of S2 file to LPA Rico
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
Page: 11 of 11