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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880912
Report Date: 05/16/2022
Date Signed: 05/16/2022 04:09:47 PM

Document Has Been Signed on 05/16/2022 04:09 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 CARE AND WELLNESSFACILITY NUMBER:
361880912
ADMINISTRATOR:AKOPYAN, HELENFACILITY TYPE:
740
ADDRESS:16055 SEQUOIA STREETTELEPHONE:
(818) 588-2894
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Helen AkopyanTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rayshaun Nickolas conducted an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Nickolas arrived and met with Administrator, Helen Akopyan. LPA Nickolas was asked to sign-in and provide temperature reading upon arrival. The administrator confirmed that there are currently no cases/exposures of COVID-19 within the facility.

During the inspection, LPA Nickolas conducted a tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA Nickolas observed appropriate postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA observed that the facility staff were wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

LPA discovered staff working at the facility that is not criminal record cleared. Based on observations made during today’s inspection, one deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Akopyan at the conclusion of the inspection..
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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 05/16/2022 04:09 PM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 05/16/2022 at 03:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: A & A CARE AND WELLNESS
FACILITY NUMBER: 361880912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearnace (e)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & file review the licensee did not comply with the section cited above by permitting S2 to work at the facility without criminal record clearance .Which poses an immediate health and safety risk to persons in care. LPA was informed S2 has worked at the facility since 5/3/2022. A civil penalty in the amount of $ 500.00 was assessed on 05/16/2022.
POC Due Date: 05/17/2022
Plan of Correction
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The licensee shall ensure S2 receives a background clearance and submit appropriate documents for S2 to be associated to the facility. Proof will be submitted to the department by 05/17/2022.
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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022


LIC809 (FAS) - (06/04)
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