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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880598
Report Date: 07/11/2022
Date Signed: 07/11/2022 02:14:55 PM

Document Has Been Signed on 07/11/2022 02:14 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
, CA 92507
FACILITY NAME:A AND M KELLY HOME CAREFACILITY NUMBER:
361880598
ADMINISTRATOR:LADY ROXANNE ARCIBALFACILITY TYPE:
735
ADDRESS:1474 KELLY AVETELEPHONE:
(909) 618-7065
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 4CENSUS: 4DATE:
07/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Angelica Punu, DSPTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to follow up on an incident. LPA initially met with DSP Angelica Punu. Administrator Roxanne Arcibal was phoned during the visit. Licensee Monaliza Dela Rosa and Administrator Arcibal arrived shortly.

On June 24, 2022, the Department received a report on Client 1 (C1). A review of incident reports revealed staff failed to submit an incident report to the Department. LPA Bueno requested a copy of the incident report from Administrator Arcibal and it was provided by email on this day. Additionally, LPA was informed the incident report had not been submitted to the Department.

The incident report revealed the incident occurred on 06/21/2022. The report stated that local law enforcement was called to the home and a report was taken. Facility staff do not have a copy of the police report but did provide the report number. Staff interviews revealed that the responding officer toured the home and subsequently found the call was unfounded.

Refer to LIC809D for deficiency cited. An exit interview was conducted where a copy of this report, LIC809D, and appeal rights were discussed and provided to the Administrator Arcibal.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2022 02:14 PM - It Cannot Be Edited


Created By: Anna Bueno On 07/11/2022 at 01:53 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
, CA 92507

FACILITY NAME: A AND M KELLY HOME CARE
FACILITY NUMBER: 361880598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2022
Section Cited
CCR
80061(b)

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REPORTING REQUIREMENTS:
Upon the occurrence, during the operation of the facility, of any of the events...a report shall be made to the licensing agency within the...next working day during...normal business hours...a written report...within seven days following the occurrence of such event.
This requirement was not met as evidenced by:
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Licensee submitted the incident to LPA Bueno during today's visit.
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The Licensee failed to report the incident to the Department until today's visit, 7/11/2022.
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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:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022


LIC809 (FAS) - (06/04)
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