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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600170
Report Date: 10/13/2022
Date Signed: 10/13/2022 03:22:53 PM

Document Has Been Signed on 10/13/2022 03:22 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:JERSEY HOMEFACILITY NUMBER:
198600170
ADMINISTRATOR:JUANITO PAGUIOFACILITY TYPE:
735
ADDRESS:17900 JERSEY AVENUETELEPHONE:
(562) 402-2229
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 4CENSUS: 4DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marylin Paguio and Zenaida Torres- Administrator & Asst. AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of conducting a required annual inspection, using the Infection Control Evaluation Tool. LPA Maldonado met with Assistant Administrator Zenaida Torres and explained the purpose for the visit. Administrator Marylin Paguio arrived shortly after to assist with the visit. The facility is an Adult Residential Facility (ARF) licensed to serve 4 developmentally disabled adults ages 18 through 59, and approved for three ambulatory clients and 1 non-ambulatory client.

The facility is a single-story home located in a residential area. The home consists of 4 bedrooms, 2 bathrooms, a kitchen, dining room, living room, laundry room, shaded patio in the back yard, and an attached garage. LPA conducted a tour of the facility with assistance of Zenaida. All 4 client bedrooms were observed to have the required furniture, linens, and sufficient lighting. Bedding, furniture, and linens were clean and in good repair. Two bathrooms were observed to have a working toilet, shower, and wash basin, and had the required grab bars and non-skid mats. Soap and paper towels were observed for hand washing. The water temperature was tested in both bathrooms and measured at 116*F, which is within the require range, per Title 22 Regulations. Room#4 is designated for the 1 non-ambulatory client and has a private bathroom and an emergency exit with a ramp. All ramps, entry/exits, and walkways were clean and free of obstructions and hazards. LPA observed the food supplies in the facility and observed more than the required 2-day of perishables and 7-day of non-perishables, with a variety of nutritious foods. All cleaning supplies/toxins were observed to be locked and inaccessible in a cabinet under the kitchen sink. A fire extinguisher was observed near the kitchen entrance to be fully charged and have a recent inspection. Carbon monoxide detectors were observed in the kitchen and in the living room. Smoke alarms were observed in each room of the home and were tested and observed to be operational. All sharps and medications are kept locked and inaccessible in the staff room. The laundry room was observed to have washing supplies locked in a cabinet and the washer and dryer were operational and in good repair.
(Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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
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: JERSEY HOME
FACILITY NUMBER: 198600170
VISIT DATE: 10/13/2022
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LPA reviewed 4 client files to confirm emergency contact is updated and have health screenings on file. LPA reviewed 3 staff records to confirm health screenings, required training certification, and fingerprint clearances.

Facility was observed to have 30 days supplies of Personal Protective Equipment (PPE), and available throughout, readily available for clients, staff, and visitors. Facility is following COVID-19 recommendations regarding screening all individuals at entry. COVID-19 signage was observed throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed for hand washing.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during today's visit.



An exit interview was conducted with Administrator and Assistant Administrator and a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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