<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607853
Report Date: 01/30/2024
Date Signed: 01/30/2024 02:00:29 PM


Document Has Been Signed on 01/30/2024 02:00 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:JENNAE CRESTFACILITY NUMBER:
197607853
ADMINISTRATOR:ERWIN JUN S. DE GUZMANFACILITY TYPE:
740
ADDRESS:19302 CHAMBLEE AVENUETELEPHONE:
(562) 331-8880
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 4DATE:
01/30/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:Administrator Erwin De GuzmanTIME COMPLETED:
02:25 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
On 01/30/24 at 10:56 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Plan of Correction (POC) visit to Jennae Crest. Upon arrival LPA was greeted by Direct Support Professional (DSP) Malou Bonifacio who contacted the Administrator, Erwin De Guzman. At 11:30 a.m. the Administrator arrived, and LPA explained the reason for the visit. LPA also discussed The TSP program with the administrator, and the administrator agreed to join the program. The NCC date of February 14th was discussed.

Prior to the visit LPA contacted Sacramento regarding the facility expired administrator certificate. According to Sacramento the recertification process was withdrawn due to non-response. LPA discussed the next steps with the administrator. LPA also discussed the 850 form to process the change of ambulatory status. LPA is requesting a new LIC 200, and updated facility sketch to proceed. The documents will be submitted by 1/5/2024.

LPA toured the facility and checked the water temperature for both bathrooms which was measured between 107.9 to 108.2 degrees F. LPA took photos of bathroom #2 shower tiles. The tiles were moving and in disrepair.

During the tour, LPA observed a missing toilet seat in bathroom #1. LPA was also informed by the administrator that the staff who required the TB test no longer work at the facility. LPA did not observe toxins or sharps unsecured within the home.


The following Deficiencies were cited on the LIC809D under Title 22 California Code of Regulations Division 6. Exit interview conducted with Malou Bonifacio, LPA contacted the administrator Erwin De Guzman via phone and reviewed the report. A copy of this report was provided, and Appeal rights given.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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 2


Document Has Been Signed on 01/30/2024 02:00 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: JENNAE CREST
FACILITY NUMBER: 197607853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2024
Section Cited
CCR
87307(d)(2)

1
2
3
4
5
6
7
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The administrator will ensure the facility is in good repair and send photo proof to LPA by POC due.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above in which the toliet seat is missing in bathroom #1 and Bathroom #2 shower tiles are indisrepair, poses a potential health, safety or personal
rights risk to persons in care.
8
9
10
11
12
13
14
Type B
02/07/2024
Section Cited
CCR87406(a)

1
2
3
4
5
6
7
(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The administrator will submit proof of administrator certificate or have an alternative administrator by POC due date.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above in which there is currently no active administrator certifcate, which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2