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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800099
Report Date: 08/06/2021
Date Signed: 08/06/2021 11:23:57 AM

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 & H QUALITY HOME CARE SERVICESFACILITY NUMBER:
361800099
ADMINISTRATOR:TURRISI, ALEJANDRA LFACILITY TYPE:
740
ADDRESS:165 GRAYSON WAYTELEPHONE:
(909) 238-6212
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:6CENSUS: 2DATE:
08/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Junior HernandezTIME COMPLETED:
11:33 AM
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 Analysts (LPAs) Melody Brown and Natalie Gayoso made an unannounced visit to conduct an annual inspection, with emphasis on infection control. LPAs were greeted and temperature taken at the door by caregiver Junior Hernandez. Administrator Alejandra Turrisi was contacted and unable to come to the facility for inspection. LPAs explained the purpose of today's visit to the Administrator over the phone. Mr. Hernandez accompanied LPAs on the tour of the inside and outside of the facility.

During today's visit, LPAs made observations pertaining to the facilities infection control measures. LPAs assert proper signage throughout the facility, with sufficient hygiene supplies and sufficient cleaning and disinfecting provisions. The facility has a 30 day supply of Personal Protective Equipment (PPE) and a 30 days supply of resident medications. The facility has a designated infection control lead person who has been tasked with tracking all Covid-19 cases and/or suspected cases, and staff trained in 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 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 resident's Physicians and all emergency agencies in the event of any Covid-19 related and/or suspected illness.

During the walk through of the outside area, LPAs observed the pool gate to be unlocked. A deficiency will be cited on the LIC 809D.

An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights to caregiver Junior Hernandez.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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
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: A & H QUALITY HOME CARE SERVICES
FACILITY NUMBER: 361800099
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee did not comply with the section cited above in 2 out of 2 residents have accessibility to the facility swimming pool which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2021
Plan of Correction
1
2
3
4
Licensee shall immediately lock the pool fence and provide copy of the key to caregivers to have access if needed. Licensee will send a picture of locked fence to LPA by POC date 08/07/2021.
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.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2