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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600398
Report Date: 10/13/2021
Date Signed: 10/14/2021 07:39:57 AM

Document Has Been Signed on 10/14/2021 07:39 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:JCM 11 GUEST HOMEFACILITY NUMBER:
198600398
ADMINISTRATOR:BALLESTEROS, JOSEPHFACILITY TYPE:
735
ADDRESS:1914 MARIGOLD STREETTELEPHONE:
(909) 622-5410
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 4DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:S-1TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA was allowed entry by S-1 and explained the purpose of today's visit. This home consists of: (4) bedrooms, (3) bathrooms, living room, kitchen, dinning area, den and an attached garage,

The following were observed/inspected:
  • COVID-19 Infection Control Practices signs were observed.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Client bedrooms inspected. There are (2) client private bedrooms and (1) shared client bedroom.
  • All clients are fully vaccinated.
  • All staff are fully vaccinated.
  • 30 day supply of medication reviewed for (4) clients (C-1 through C-4).
  • PPE supplies observed. Additional PPE supply is stored inside the office.
  • Incontinence supply observed.
  • Hygiene supplies observed.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Clients were socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-1.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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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