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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600170
Report Date: 10/14/2024
Date Signed: 10/14/2024 03:09:16 PM

Document Has Been Signed on 10/14/2024 03:09 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JERSEY HOMEFACILITY NUMBER:
198600170
ADMINISTRATOR/
DIRECTOR:		JUANITO PAGUIOFACILITY TYPE:
735
ADDRESS:17900 JERSEY AVENUETELEPHONE:
(562) 402-2229
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 4CENSUS: 4DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:22 PM
MET WITH:Administrator Juanito PaguioTIME VISIT/
INSPECTION COMPLETED:
03:23 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mayra Cota and Jewel Baptiste conducted an unannounced annual visit at the facility using the CARE inspection tool.

The facility is licensed to served three (3) ambulatory only and one (1) non-ambulatory, developmentally disabled adults ages 18-59. Facility is a single home located in a residential neighborhood, and consist of a receiving room, kitchen and dining area, one (1) live-in staff bedroom, four (4) client bedrooms, two (2) bathrooms, one (1) laundry room, living room with a non-working fireplace, an attached garage, a front yard, and a back yard.

LPAs conducted a tour of the facility with Eleuterio Nebria and observed the following: (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. Bedroom #1 mattress had a hole. 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 104.4*F-106.7*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. Sharps and medications were locked in Staff bedroom. 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: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JERSEY HOME
FACILITY NUMBER: 198600170
VISIT DATE: 10/14/2024
NARRATIVE
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The outdoor grounds were toured and inspected, and 1 side of the building had broken furniture, over grown plants and was inaccessible to clients. The garage contained bottled water, toiletries, personal care supplies, stored locked and inaccessible to the clients. LPA did not observe a shaded seat area for clients.

Exit interview conducted with Eleuterio Nebria, a copy of this report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/14/2024 03:09 PM - It Cannot Be Edited


Created By: Mayra Cota On 10/14/2024 at 02:43 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JERSEY HOME
FACILITY NUMBER: 198600170

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which LPAs observed broken furniture, over grown grass on the side of the building, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2024
Plan of Correction
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The Administrator will ensure the back yard is clean of debris and furniture with photo proof due by POC due date.
Type B
Section Cited
CCR
85088(c)(1)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 4 mattresses had a hole, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2024
Plan of Correction
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The Administrator will ensure all clients furnitaure is in good repair at all times. Photo proof is due to LPA by POC due date.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Mayra Cota
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/14/2024 03:09 PM - It Cannot Be Edited


Created By: Mayra Cota On 10/14/2024 at 02:43 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JERSEY HOME
FACILITY NUMBER: 198600170

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which LPAs did not observe a shaded seated area, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2024
Plan of Correction
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The Administrator will ensure the clients have a shaded seated area. Photo proof is due to LPA by POC due date.
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview the licensee did not comply with the section cited above in which LPAs was unable to review Emergeny Disaster Plan. The ADministrator stated they will email the plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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The Administrator will ensure a compy of the facilities Emergency Dister plan is available in the facility at all times.A copy of the plan is due to LPA by POC due date.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Mayra Cota
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


LIC809 (FAS) - (06/04)
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