361881039-2-14-2024-56-AS-JPRO-D2FVD9-20240214152022

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881039
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:20:26 PM

Document Has Been Signed on 02/14/2024 03:20 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 & M TEAKWAY HOME CARE		FACILITY NUMBER:	361881039
ADMINISTRATOR:	ROSA DELA, MONALIZA A		FACILITY TYPE:	735
ADDRESS:	7979 TEAK WAY		TELEPHONE:	(909) 527-3780
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91730
CAPACITY:	4	CENSUS: 4	DATE:	02/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Monaliza DeLa Rosa, Administrator		TIME COMPLETED:	03:25 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) Javier Prieto conducted an unannounced annual required visit. LPA was greeted and granted entry to the facility by Administrator Monaliza DeLa Rosa. LPA explained the nature of today's visit. LPA accompanied with Ms DeLa Rosa , conducted a general overall inspection, which included, but was not limited to the following: Physical Plant: The facility was not operating over capacity or beyond any conditions and limitations on the license. There are no pools or other bodies of water located on the premises. There are no ammunition or firearms kept in the home. Facility is being maintained at a comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Hot water temperature was measured at 112 degrees Fahrenheit in all resident bathrooms. There are grab bars for each toilet, bathtub and shower used by residents. Smoke detectors and carbon monoxide devices were tested and found to be in working order. Last disaster drill was conducted 02/09/2024 Food Service: There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods. Care and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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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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
, CA 92507

FACILITY NAME: A & M TEAKWAY HOME CARE	FACILITY NUMBER: 361881039
	VISIT DATE: 02/14/2024

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Record Review: LPA requested and reviewed (4) resident and (2) staff files. LPA reviewed staff files for current CPR/1st aide certificates, TB results, and required training's. LPA reviewed client files for admissions agreement, physician report, and IPP

Administration: LPA did not observe any excluded individuals on the premises at time of visit. The Administrator appears to be on the premises a sufficient number of hours to manage and oversee the business operation.

Medical Related Services: Medications are centrally locked in the staff office and inaccessible to residents in care. Medications are being administered as prescribed by physician's directions.

No deficiencies cited. An exit interview was conducted where this report was provided and discussed with MS DeLa Rosa .

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC809 (FAS) - (06/04)

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