365530109-9-13-2024-56-AS-MMAE-D942HF-20240913172439

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530109
Report Date: 09/13/2024
Date Signed: 09/13/2024 05:24:55 PM

Document Has Been Signed on 09/13/2024 05:24 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 & 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: 2	DATE:	09/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Ahmad Hazameh		TIME COMPLETED:	05:30 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Magda Malcore and Eldin Serrano made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPAs met with Administrator, Ahmad Hazameh and discussed the purpose of the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (6), and a current census of (2). LPAs conducted a general inspection of facility, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. The backyard activity space is shaded and fenced with self-latching gates. The facility is maintained at a comfortable temperature. Resident bedrooms were furnished with beds, bed linen, night stands, chairs, and bedroom lighting. Resident bathroom was maintained clean and fixtures were operating properly. The hot water temperature in the bathroom measured at 108 degrees F. The facility is equipped with operating smoke/carbon monoxide alarms and telephone service. The facility has posted in a common area Community Care Licensing complaint poster, Ombudsman poster, facility license, and emergency evacuation plan. LPA's observed insecticides kept in unlocked cabinet in the kitchen. LPA's observed cleaning supplies kept in an unlocked closet. The Administrator placed the toxins in a locked closet. Deficiency cited.

Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply was sufficient for number of residents in care. The facility’s refrigerator and freezer were operating properly

Care & Supervision: The facility staff schedule reflects 24 hours a day, 7 days a week staff coverage.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A & A COMFORT CARE LLC	FACILITY NUMBER: 365530109
	VISIT DATE: 09/13/2024

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Health Related Services: The facility maintains record of resident’s medications and medications were centrally stored in a locked cabinet.

Record Review: Resident files were reviewed for admissions agreements, physician’s reports, appraisals, needs and services plans. LPA's review of resident files reveal, resident#1 admissions agreement was not signed by resident. Deficiency cited. Staff files reviewed had first Aid/CPR certifications, criminal record clearances, training, and health screenings. The Administrator’s certification, facility’s insurance and emergency drill training are up-to-date.

Based on LPAs observations and records reviewed, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where the licensing reports were discussed. Copies of the reports were provided with appeal rights to the Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/13/2024 05:24 PM - It Cannot Be Edited

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 & A COMFORT CARE LLC	FACILITY NUMBER: 365530109
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations, the licensee did not comply with the section cited above by not maintaining cleaning supplies and insecticides locked and inaccessible to residents; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/14/2024
	Plan of Correction
1 2 3 4	The Administrator locked the toxins during LPAs visit.No futher action required.

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/13/2024 05:24 PM - It Cannot Be Edited

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 & A COMFORT CARE LLC	FACILITY NUMBER: 365530109
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above by resident #1's admissions agreement was not signed by resident; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/14/2024
	Plan of Correction
1 2 3 4	The Administrator had resident sign the admissions agreement during LPA's visit. no further action is required.

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024

LIC809 (FAS) - (06/04)

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