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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413071
Report Date: 08/09/2022
Date Signed: 08/09/2022 01:27:17 PM


Document Has Been Signed on 08/09/2022 01:27 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:AM/PM ASSURED CAREFACILITY NUMBER:
336413071
ADMINISTRATOR:PEARL AGUINALDOFACILITY TYPE:
740
ADDRESS:2 DICKENS CT.TELEPHONE:
(760) 321-5085
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:6CENSUS: 5DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Russell Aguinaldo, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA arrived at approximately 11:46 AM, signed in and utilized hand sanitizer. The LPA met with Administrator, Russell Aguinaldo, and informed him of the purpose of her visit. There are currently no cases of COVID-19 within the facility.

During today's visit, the LPA toured the facility and made observations pertaining to the facility's infection control measures. The LPA observed sufficient cleaning and disinfecting provisions and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and ensuring disinfection provisions are in adequate quantities. The facility has a plan in place (Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report) which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, 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 residents regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During this visit the LPA observed a lock on the exterior emergency side gate. A citation will be issued, along with a civil penalty. The LPA also observed Staff One (S1) to be working in the facility without a California Clearance. A citation will be issued, along with a civil penalty.

An exit interview to review this report was conducted with Aguinaldo and a copy of this report was provided, along with Appeal rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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 2


Document Has Been Signed on 08/09/2022 01:27 PM - It Cannot Be Edited

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
RIVERSIDE, CA 92507


FACILITY NAME: AM/PM ASSURED CARE
FACILITY NUMBER: 336413071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The LPA observed one exterior side gate to be locked. This is the only emergency gate located at the side of the facility. This poses an immediate safety risk to persons in care.
POC Due Date: 08/09/2022
Plan of Correction
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The Administrator removed the lock immediately. POC cleared.
Type A
Section Cited
CCR
87355(e)(1)
Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department...This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of three uncleared staff members. The LPA observed Staff One (S1) to be working in the facility. S1 does not have a California Clearance. This poses an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 08/09/2022
Plan of Correction
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S1 immediately left the facility, prior to the LPA's departure. POC cleared.

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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2