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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600173
Report Date: 08/20/2021
Date Signed: 08/20/2021 05:12:11 PM

Document Has Been Signed on 08/20/2021 05:12 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:J-J ADULT CARE HOMEFACILITY NUMBER:
198600173
ADMINISTRATOR:JOSE & JEAN TIMBOLFACILITY TYPE:
735
ADDRESS:1233 BOYNTON STREETTELEPHONE:
(818) 243-0628
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY: 6CENSUS: 6DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Armamento Gertrudes, TIME COMPLETED:
05:15 PM
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Licensing Program Analysts (LPAs) Nune Margaryan and Nina Galarza conducted an unannounced annual inspection of the facility and met with Gertrudes Armamento, shortly after Administrator Giovani Angeles arrived. The purpose of the visit was explained. The facility is licensed for an Adult Residential Facility, capacity of 6 developmentally disabled clients. The current census is (6), and during inspection, all (6) clients were present in the facility, with (3) staff. The facility has (5) bedrooms, which (2) are shared rooms, and (2) are private for clients. One room is used for staff, and the facility has (3) bathrooms, (1) bathroom was for staff and not accessible to clients. 2nd bathroom is shared bathroom for clients. 3rd bathroom is a private bathroom, that is located in room 4.

A physical plant tour was conducted at 3:10 pm with the staff Armamento Gertrudes and the following were observed:

LPAs observed COVID-19 informational postings at the entrance and in various locations throughout the facility.

LPAs were screened upon arrival.

The kitchen appeared clean and the appliances and fixtures functional. The kitchen / refrigerator is stocked with the required two (2) days perishable and seven (7) days non-perishable food supply for all clients. LPAs observed fresh fruits and snacks for residents. The food was also stored properly. Knifes and cleaning solutions are observed locked in a cabinet.

Laundry area observed near kitchen area.

All bedrooms observed clean, properly furnished and had appropriate bedding and linens.

Extra blankets, pillows, bedsheets, and cleaning solutions are observed locked in a cabinet. There are sufficient lighting in all rooms to ensure comfort and safety for clients.

Continued 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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: J-J ADULT CARE HOME
FACILITY NUMBER: 198600173
VISIT DATE: 08/20/2021
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Bathrooms observed clean, adequately supplied with soap, paper towels, toilet paper. Non-skid mat and grab bars observed in tub/shower area. Extra supply of hygiene products observed. The bathrooms are clean and have the required hygiene items.

Water temperature was at measured at 108.5 degrees at time of visit. The fire extinguisher was up to date and operational.

Common areas included living and dining areas appeared clean and were properly furnished.

LPAs reviewed client medications records and stored medication. All medications were properly labeled and administered as directed by the physician. Medication cabinet observed in the kitchen area observed locked. The front and backyard are well maintained.

The backyard has a shaded area with patio furniture. There is no pool or other large bodies of water.

Exit and passageways were free of obstructions.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, no deficiency was observed or cited during this visit



Exit Interview Conducted and Copy of Report Issued to Administrator Giovani Angeles.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
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