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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801816
Report Date: 01/20/2022
Date Signed: 01/20/2022 11:00:34 AM

Document Has Been Signed on 01/20/2022 11:00 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MSJI HOME INCFACILITY NUMBER:
197801816
ADMINISTRATOR:INDIRA BHAVSARFACILITY TYPE:
735
ADDRESS:1324 JUANITA AVETELEPHONE:
(909) 592-6003
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 5DATE:
01/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:16 AM
MET WITH:Berliani Simamora, CaregiverTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with caregiver, Berliani Simamora and explained the reason for the visit. Administrator, Indi Bhavsar was called and notified of the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff and resident files.

All 3 client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Both bathrooms were toured. Bathrooms have the required hygiene items. The hot water was 104.6 degrees which is within the required 105 - 120 degrees. Cleaning supplies and chemicals are locked in the staff office. The office also contains all the PPEs. Facility has at least a 30-day supply of PPE. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are cleaning and working properly. There is additional food in the second refrigerator in the office. The common areas such as living room and dining room are clean and have the required furniture. The backyard has a shaded area and sitting area. Signs are posted throughout the home to remind staff and residents to wear masks and wash hands. Staff were observed checking visitor's temperature at the time of entry.

LPA reviewed resident files to confirm emergency contacts have been updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed 5 residents' medications. Medications are documented and stored properly.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to caregiver.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2022
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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