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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600398
Report Date: 07/07/2023
Date Signed: 07/07/2023 02:10:48 PM

Document Has Been Signed on 07/07/2023 02:10 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
GREATER LA AC/SC, 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:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Christopher Ballesteros/S-1TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Christopher Ballesteros/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/dining area, den and an attached garage. All clients from this home receive case management services provided by San Gabriel Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Operational Requirements: Last Disaster Drill was conducted on 06/02/23. Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms were tested and operable. Fire extinguisher is located in the kitchen and appeared to be full. Carbon monoxide detector is located in the hallway (tested and operable). Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Water temperature measured at 107.0*.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JCM 11 GUEST HOME
FACILITY NUMBER: 198600398
VISIT DATE: 07/07/2023
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Staffing: There is sufficient staffing at the facility. Administrator Certificate for Joseph Ballesteros expires on 11/23/24 and HIV and TB Training certificate is not on file (deficiency cited). Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Staff #1 (S-1) and Staff #5 (S-5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff have on-going training.

Client Rights-Information: Client rights are posted and included in Client files. Per Administrator, there are no clients using postural supports.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #4 (C-4). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Consent For Medical Treatment, Individual Program Plan/IPP, House Rules, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. There are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and bubbled packed. LPA reviewed medication for C-1 through C-4. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per Administrator, there are (0) clients with restricted health condition plan.

Disaster Preparedness: The facility does not have the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA provided technical assistance as to how to retrieve this form from the DSS website. Deficiency cited.
Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to Christopher Ballesteros.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2023 02:10 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 07/07/2023 at 01:47 PM
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: JCM 11 GUEST HOME
FACILITY NUMBER: 198600398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review and administrator confirmation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Administrator to submit proof of HIV and TB training registration to LPA Irra by POC due date noted above.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record view, the licensee did not comply with the section cited above as the facility did not have a complete disaster and mass casualty plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Administrator to complete and submit a disaster and mass casulty plan to LPA Irra by POC due date noted above.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
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