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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412448
Report Date: 06/29/2022
Date Signed: 06/29/2022 03:58:03 PM


Document Has Been Signed on 06/29/2022 03:58 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:AMI RICHARDSONFACILITY NUMBER:
366412448
ADMINISTRATOR:VERGEL SANTOSFACILITY TYPE:
735
ADDRESS:1619 RICHARDSON STREETTELEPHONE:
(909) 328-2815
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92408
CAPACITY:6CENSUS: 4DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:DSPs - Jose and Graciela BandaTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on infection control. LPA met with live-in DSPs, Graciela and Jose Banda. Administrator Vergel Santos arrived shortly.

During the inspection, LPA and staff conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. LPA observed that the facility had several COVID-19 related postings throughout the facility. The facility was also equipped with sufficient hand hygiene supplies and sufficient cleaning and disinfecting provisions. This facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the responsible parties and medical personnel in the event the client presents with any COVID-19 symptoms.

During today's visit, LPA and staff observed that the lock of the undersink cabinet that houses cleaning agent are broken. This poses a potential risk to the health and safety of clients in care. Refer to LIC-809D for deficiency cited.

An exit interview was conducted where a copy of this report was discussed and provided to Administrator Santos at the conclusion of the inspection.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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 06/29/2022 03:58 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: AMI RICHARDSON
FACILITY NUMBER: 366412448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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
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Based on observation and staff interview, the licensee did not comply with the section cited above as LPA and staff observed the undersink cabinet lock for cleaning agent is broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2022
Plan of Correction
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Licensee shall submit proof of fixed cabinet lock to CCL by end of POC day.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
LIC809 (FAS) - (06/04)
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