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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600173
Report Date: 06/10/2022
Date Signed: 06/10/2022 11:55:48 AM

Document Has Been Signed on 06/10/2022 11:55 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: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: 5DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Administrator Giovani AngelesTIME COMPLETED:
12:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an announced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA was met by Dsp Gertrude Armamento and explained the purpose of the visit. Administrator Giovani Angeles arrived a short time later and LPA discussed purpose of visit. Facility is an Adult Residential facility. Home is level 4 home. The facility consists of 4 client rooms, 1staff room, (3) restrooms, kitchen and dining room, and 2 living rooms. Water was measured between 105.8 -106.0 degrees, toilets and showers observed operable.
The last fire drill was completed on April 24, 2022 Administrator certificate expires June 21, 2022.

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has designated isolation room.
Five (5) rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not wearing mask at time of visit but adhering to social distancing guidelines.
· Sufficient supply of non-perishable foods for 7 days was observed.
· A posted Emergency Disaster Plan was not observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies cited (see 809D for details)

Exit interview was conducted with Administrator Giovani Angeles. A copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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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Document Has Been Signed on 06/10/2022 11:55 AM - It Cannot Be Edited


Created By: Alberto Lopez On 06/10/2022 at 11:10 AM
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: J-J ADULT CARE HOME
FACILITY NUMBER: 198600173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)

(3) All toliets, handwashing and bathing facilities shall be maintained in clean and sanitary operating conditon.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, room 4 bathroom sink is leaking from the base and water is seeping into the floor of the room which has water damage. Also, bathroom has wall with water damage by the shower and grab bar, medicine cabinet door and towel rack is in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2022
Plan of Correction
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Administrator agreed to repair leaking sink, grab bar, towel rack, bathroom cabinet door and floor section in room 4 where water has leaked under. Administrator will send proof of repair to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


LIC809 (FAS) - (06/04)
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