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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600398
Report Date: 06/24/2022
Date Signed: 06/24/2022 11:17:52 AM

Document Has Been Signed on 06/24/2022 11:17 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:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:S-1TIME COMPLETED:
11:30 AM
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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 met with S-1 and discussed the purpose of today's visit.

This facility consists of (4) bedrooms/(1) of which is used as an office, (3) bathrooms, living room, kitchen/dinning area, den and an attached garage.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed. Additional PPE supplies are stored inside the office.
  • Restrooms have hand soap and paper towels. Hand sanitizers observed in common areas throughout this facility.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Additional food supply including water are stored inside the office.
  • Per S-1, all (4) clients have both vaccines and 1st booster.
  • Per S-1, there are (7) staff members have both vaccines and 1st booster.
  • Medication reviewed for (4) Clients (Client #1 through Client #4).
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were be socially distanced according to local public health guidelines.

LPA discussed the infection control plan which will be submitted to CDSS by 06/30/2022. Exit interview conducted, a copy of this report and Appeal Rights were provided to S-1. LPA was having technical difficulties during this visit.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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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