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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881511
Report Date: 07/29/2024
Date Signed: 07/29/2024 11:58:23 AM

Document Has Been Signed on 07/29/2024 11:58 AM - 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
RIVERSIDE, CA 92507
FACILITY NAME:AMPM COMFORT CARE, INC.FACILITY NUMBER:
331881511
ADMINISTRATOR/
DIRECTOR:		AGUINALDO, RUSSELLFACILITY TYPE:
740
ADDRESS:2 DICKENS COURTTELEPHONE:
(818) 966-0088
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY: 6CENSUS: 5DATE:
07/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Russell Aguinaldo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:30 AM, LPA met with Administrator Russell Aguinaldo. An initial application for Change of Ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 03/20/2024 for a total capacity of six; five (5) non-ambulatory and one (1) bedridden residents-approved for Room #1 only. Fire clearance was granted on 10/11/2023. Hospice waiver approved for six (6) residents. LPA Delgado observed the following:

Structure:
Facility was a one-story house with five (5) resident bedrooms, four (4) resident bathrooms, living room, dining area, kitchen and casita for caregivers. There was an attached one car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the master bedroom to control entire house.
Bedrooms:
Each resident bedroom #2, #3, #4 and #5 will accommodate any non-ambulatory resident, shared bedroom #1 will accommodate one (1) bedridden resident and one (1) non-ambulatory resident; room was not set-up for two clients. Five (5) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.


(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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
RIVERSIDE, CA 92507
FACILITY NAME: AMPM COMFORT CARE, INC.
FACILITY NUMBER: 331881511
VISIT DATE: 07/29/2024
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Bathrooms:
The four (4) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:15 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 131.0 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked cabinet with cleaning supplies located in the kitchen; sharps will be relocated in a drawer inside the kitchen. There was adequate room for food storage. LPA observed the stove to have two burners not working. Refrigerator/freezer were in working condition and had sufficient storage for perishable food; freezer handle missing. There was adequate seating for meals for all clients. Washer and dryer was located inside the garage. Laundry detergents and cleaning supplies were observed in a locked cabinet in the kitchen away from residents.
Living/Family room:
There was a living/family room for all residents with furniture for seating and TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway; no personal hygiene care supplies observed.
Yards/Outside:
Patio table and chairs were observed in the backyard. There was a gate on the East side of the property that needs a self-latching lock and the small gate needs a self-latching lock to be repaired. All outdoor pathways were free of obstructions. There is debris of medical equipment in front of the storage that needs to be discarded.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the main hallway. Obudsman poster and Let-Us-No poster observed.

(Continued on Page 3)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
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
RIVERSIDE, CA 92507
FACILITY NAME: AMPM COMFORT CARE, INC.
FACILITY NUMBER: 331881511
VISIT DATE: 07/29/2024
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General items:
Two (2) fire extinguishers were charged and located in the kitchen and main hallway of bedrooms. Nine (9) smoke alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order. Four (4) exterior window screens needs to be replaced. Facility has a pool with a perimeter gate that is 5 feet tall and locked. Client/staff records will be stored in a locked cabinet in the Family room. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Insufficient Emergency food and water was observed. The facility sketch showed a laundry room and there were no machines to do laundry observed. Component III was completed on July 25, 2024 at the Riverside regional office.
Pre-Licensing is incomplete and the following corrections to be resolved by 8/12/2024:

obtain additional 72-hour emergency food supply
obtain additional emergency water
obtain paper towels holders
obtain warning hot water label
obtain personal hygiene care supplies
obtain a new location for sharps
remove gate inside of kitchen
remove debris in the backyard
remove latch from pantry room door
repair East gate and small gate with self-latching locks
repair bathtub knob for room #1
repair 2 stove burners
repair slide-out drawers inside kitchen for pots/pans
repair garbage compactor
replace kitchen ceiling light bulb
(Continued on Page 4)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
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
RIVERSIDE, CA 92507
FACILITY NAME: AMPM COMFORT CARE, INC.
FACILITY NUMBER: 331881511
VISIT DATE: 07/29/2024
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(Continued from Page 3)

replace bathroom drawers handles
replace 4 exterior window screens
replace all bathrooms with lidded trash cans
set-up bedroom #1 for shared room
update Facility sketch to CAB


An exit interview was conducted, and a copy of this report was given.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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