365530109-9-7-2023-56-AS-ABUO-CVFV78-20230907161044

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530109
Report Date: 09/07/2023
Date Signed: 09/07/2023 04:11:08 PM

Document Has Been Signed on 09/07/2023 04:11 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 & A COMFORT CARE LLC		FACILITY NUMBER:	365530109
ADMINISTRATOR:	HAZAMEH, AHMAD		FACILITY TYPE:	740
ADDRESS:	17455 MADRONE ST.		TELEPHONE:	(951) 332-1095
CITY:	FONTANA	STATE: CA	ZIP CODE:	92337
CAPACITY:	6	CENSUS: 0	DATE:	09/07/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:54 PM
MET WITH:			TIME COMPLETED:	04:15 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 Analysts (LPA) Anna Bueno conducted an announced pre-licensing inspection of the facility. LPA met with Licensees Ahmad Hazameh and Ahmad Salamah who were informed of the purpose of today's visit. There are currently no residents in care. Application: The application is for a Residential Care Facility for the Elderly. Fire clearance has been granted for six (6) ambulatory residents. Fire inspection was on conducted on April 25,2023 by the Fontana Fire Prevention Office. Buildings and Grounds: The home is composed of five (5) resident bedrooms -one of which will be utilized as the staff office, three (3) bathrooms -two of which are dedicated for resident use, a laundry area, a living room, a kitchen and dining area, and a backyard patio. LPA and Licensees toured the interior and exterior of the facility. This facility has no bodies of water. A shaded backyard patio area is available for residents. LPA and Licensees observed that side gate is unlocked and free of obstruction. The facility has a working telephone for residents use. LPA and Licensees observed charged fire extinguishers and, Licensee tested smoke alarms and carbon monoxide detectors that were operable. The facility had a complete first aid kit and manual. Storage and Supplies: Activities were observed to be available in the living area and appear to be a sufficient amount for the requested census. Medications will be kept secured in a medication cart kept in the staff office. A standing locked cabinet is available for facility files and resident files. The first aid kit was observed to be available and complete. Linens, and equipment are all in good repair and sufficient for approved census. Food Service and Laundry: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. There is a secured storage for sharps, and cleaning supplies and toxins were locked in a closet.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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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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 & A COMFORT CARE LLC	FACILITY NUMBER: 365530109
	VISIT DATE: 09/07/2023

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Bedrooms and Bathrooms: Resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by LPA between 113-117 degrees Fahrenheit.

Component III was discussed with Administrator. The pre-licensing inspection is complete and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations. An exit interview was conducted where this report was discussed with and a copy was provided Licensee at the conclusion of the inspection.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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