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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600173
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:52:45 PM

Document Has Been Signed on 05/16/2024 03:52 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
Lookup Error,
, CA
FACILITY NAME:J-J ADULT CARE HOMEFACILITY NUMBER:
198600173
ADMINISTRATOR/
DIRECTOR:
JOSE & JEAN TIMBOLFACILITY TYPE:
735
ADDRESS:1233 BOYNTON STREETTELEPHONE:
(818) 243-0628
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY: 6CENSUS: 5DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Staff Gertrudes ArmamentoTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Jose Villalobos conducted the unannounced Annual Inspection visit using the Compliance And Regulatory Enforcement (CARE) Tool. LPA met with Staff Gertrudes Armamento and the purpose of the visit was discussed. The following tool domains were completed:

Infection Control: LPA observed the facility has sufficient PPE supplies. Infection Control Plan was collected and reviewed.

Physical Plant and Environmental Safety: The facility is licensed to serve up to (6) developmentally disabled adults ages 18 to 59 years old, of which (4) may be non-ambulatory. There are currently 5 clients at this home of which (2) are non ambulatory. Facility is located in a residential area and consist of (4) client bedrooms, 3 bathrooms, (2) living rooms, kitchen with dining area, covered backyard deck, and a detached garage. The facility was inspected during the physical plant tour. No passageways or paths were obstructed.
Operational Requirements: Facility is operating within its approved clearance. Activities Calendar observed

Staffing: The facility has a sufficient amount of staff per shift in the facility. LPA reviewed staff roster to verify that there is a staff present during the Nightshift.

Personnel Records-Training: Personal records centrally stored. LPA inspected six (6) staff files. All staff are background check cleared and associated with the facility. All the staff files have the required Title 22 documents. The administrators certificate is currently active.

Client's Right - Information: No client in the facility required any postural support at the present time. Required postings observed.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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
Lookup Error,
, CA
FACILITY NAME: J-J ADULT CARE HOME
FACILITY NUMBER: 198600173
VISIT DATE: 05/16/2024
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Food Service: Supply of Non perishables and perishables was observed. Food supply was adequately stored. Pesticides and other toxic substances were not stored with the food supply. Kitchen area was clean.
Food menu was observed.

Client Records/Incident Reports: Client files are centrally stored. LPA reviewed five (5) client files. Client files are up to date and have required documents.

Health Related Services: Medication is centrally stored and locked making them inaccessible to clients in care. LPA reviewed five (5) Client Medications. LPA did not observe any medication mismanagement or errors in the documentation of medications.

Incidental Medical Services: No client in the facility has any restricted health condition plan. There are no clients in care with prohibited or restricted health conditions. First Aid kid observed and available when needed.

Disaster preparedness: The facility has an updated emergency disaster plan. Facility has client information readily available in case of emergencies.

Emergency Intervention: The facility are not using any restraints in the facility.

Per Title 22 Regulations, no deficiencies are being cited on todays visit.

Exit Interview conducted. A copy of the report was provided
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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