361881039-5-3-2023-56-AS-VCHN-CRGSLB-20230503135803

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881039
Report Date: 05/03/2023
Date Signed: 05/03/2023 01:58:17 PM

Document Has Been Signed on 05/03/2023 01:58 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 & M TEAKWAY HOME CARE		FACILITY NUMBER:	361881039
ADMINISTRATOR:	ROSA DELA, MONALIZA A		FACILITY TYPE:	735
ADDRESS:	7979 TEAK WAY		TELEPHONE:	(909) 618-7065
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91730
CAPACITY: 4		CENSUS: 3	DATE:	05/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:			TIME COMPLETED:	02:15 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) Victoria Chitgian arrived unannounced to the facility for a required annual inspection. Facility is an Adult Residential Facility licensed for four (4) non-ambulatory clients. LPA met with Administrator Monaliza Dela Rosa. At the time of the visit, two clients were present at the facility. LPA toured the facility inside and outside. Outdoor and indoor passageways were kept free of obstruction. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. LPA toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional linen and extra hygiene items for the clients. The facility had a complete first aid kit available and the last disaster drill was conducted on 4/14/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Centrally stored medications were kept in a safe and locked cabinet. LPA toured the client bathrooms. LPA measured the hot water temperature in the bathroom. The hot water temperature measured 115 degrees Fahrenheit. LPA observed emergency supplies in the garage. The outside of the facility had a shaded area with a table and chairs. The facility does not have a pool or bodies of water. LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. Administrator file lacked the required HIV and TB training as required every 2 years. Administrator stated it has expired and they will have to re-enroll for certification. Deficiency issued. Client files had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. LPA observed the signs and postings in the common area. LPA did not observe the facility policy on visitation. Administrator stated they do not currently have one in place but will work on having one created. Deficiency issued. LPA observed the Emergency Disaster Plan (LIC 610D) was posted, however was not updated as of 2020.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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 05/03/2023 01:58 PM - It Cannot Be Edited

Created By: Victoria Chitgian On 05/03/2023 at 01:31 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 & M TEAKWAY HOME CARE	FACILITY NUMBER: 361881039
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 observation, interview, and record review, the licensee did not comply with the section cited aboveas a training on HIV and TB was not available for review, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Administrator agrees to submit training enrollment for HIV and TB to the LPA via email by POC due date above.

Type B

Section Cited

CCR

80072(e)

(e)The information specified … including the visiting policy as stated in the admissions agreement shall be prominently posted in areas accessible to clients and their visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the facility did not comply with the section cited above as the visitation policy is not posted in a common area, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Administrator will create and post a facility visitation policy and submit photo proof to LPA via email by POC due date above.

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 Malagon

LICENSING EVALUATOR NAME:

Victoria Chitgian

LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

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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 & M TEAKWAY HOME CARE	FACILITY NUMBER: 361881039
	VISIT DATE: 05/03/2023

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Administrator agreed to update the plan as required annually and stated there are no changes made. Technical Violation issued. Facility has secured each consumer’s personal property and cash resources. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.

Two (2) deficiencies were issued during this visit. One technical violation issued. An exit interview was conducted where this report, LIC 809, LIC-809-D, LIC 9102, and appeal rights was discussed and provided to the Administrator, Monaliza Dela Rosa at the end of the visit.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

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