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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880906
Report Date: 12/08/2021
Date Signed: 12/08/2021 02:30:37 PM

Document Has Been Signed on 12/08/2021 02:30 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
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: 8DATE:
12/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ahmed Qasim, ManagerTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Goldenberg is conducting this case management visit to address violations observed during the course of a complaint investigation conducted on this day. LPA tour of this facility revealed that there are eight (8) residents residing at the facility. This facility is licensed for six (6) adult residents. This is a violation of the approved fire clearance and poses a risk to the health and safety of residents in care.

This report was reviewed with and a copy was provided to the facility representative. Please see LIC809D.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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 12/08/2021 02:30 PM - It Cannot Be Edited


Created By: Amy Goldenberg On 12/08/2021 at 01:57 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: 12/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2021
Section Cited
CCR
80020(a)

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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.
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LIcensee must make arrangement to relocate residents in order to regain compliance with their fire clearance and capacity limitations by POC date 12/09/2021.
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The facility has failed to meet the requirements of their fireclearance capacity of 6 by retaining 8 residents. This poses a risk to the health and safety of residents in care.
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A civil penalty accompanies this deficiency.

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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:Nedra Brown
LICENSING EVALUATOR NAME:Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2021


LIC809 (FAS) - (06/04)
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