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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600170
Report Date: 10/17/2023
Date Signed: 10/17/2023 01:52:29 PM

Document Has Been Signed on 10/17/2023 01:52 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:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Administrator Marilyn PaguioTIME COMPLETED:
02:10 PM
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On 10/17/23 at 11:39 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Jersey Home. Upon arrival LPA was greeted by Direct Support Professional (DSP) Eleuterio Nebria who contacted the Administrator. The Administrator Marilyn Paguio arrived at 12:05 and LPA explained the reason for the visit. This home is licensed to serve (4) Developmentally Disabled Ambulatory Adults, (1) non-Ambulatory and (3) Ambulatory Adults ages 18 through 59. The home is vendored through Harbor Regional Center. There were (0) clients in care during the time of this visit, the (4) clients were at the day program. The last emergency disaster/fire drill was conducted on 10/1/2023. The Administrator Certificate expired on 7/5/2023 #6005366735. LPA checked CCLD pending list and observed the facilities administrator is on the list. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (4) client files, medications, and medication administration records for (4) clients and P&I.

This home contains 4 bedrooms, 1 staff bedroom, 2 bathrooms, 2 living room, kitchen, dining room and an attached garage. LPA toured the physical plant with S1 and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 106.7*F-117.3*F respectively. The smoke detectors were battery operated and individually tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (1) fire extinguisher located in the hallway, charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans. The cleaning agents and toxins was locked and secured in a kitchen cabinet. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home. (Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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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: 10/17/2023
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The outdoor grounds were toured and inspected, and the patio was well maintained. The garage contained bottled water, toiletries, personal care supplies, stored locked and inaccessible to the clients.

Exit interview conducted with Eleuterio Nebria, a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
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