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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600686
Report Date: 05/09/2023
Date Signed: 05/09/2023 03:19:53 PM

Document Has Been Signed on 05/09/2023 03:19 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JML BOARD & CAREFACILITY NUMBER:
198600686
ADMINISTRATOR:FIERRO, GILBERTFACILITY TYPE:
735
ADDRESS:191 EAST WASHINGTON BLVD.TELEPHONE:
(626) 797-5022
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 4CENSUS: 4DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:TIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced site visit. Upon arriving at the facility, LPA met with staff Ray Francisco and was later joined by the Administrator Gilbert Fierro who assisted with the visit. The facility is licensed to serve four (4) Developmentally Disabled Clients ages 18 - 59 years of age. The facility is approved for four (4) Ambulatory Clients only. Currently, there are four (4) clients in placement, of which 1 is in rehabilitation center. During today's visit, LPA used the CARE TOOL and conducted a tour of the physical plant.

The facility is located in a residential area. A tour conducted alongside with Ray Francisco of the single-story facility includes: Four (4) client bedrooms, 1 (one) staff room, 2 (two) bathrooms, living room, kitchen / dining area, laundry room , garage (detached/locked) and indoor/outdoor area. The staff room is kept locked and inaccessible to clients at all times. All medications are kept locked in kitchen cabinet and inaccessible to other clients. The bathrooms are clean and operational. Client bedrooms were observed with adequate furniture .The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Solutions, toxins, knives, and hazardous items are in a secured cabinets (laundry room and kitchen area) and inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. LPA observed a pull-switch fire alarm in the living room. The fire extinguisher was observed in the kitchen area and was fully charged. Fire Drill conducted on 1/12/23. The first-aid kit is fully stocked. The front yard is well landscaped with steps that leads to the entry. Backyard observed and no body of water was observed. Passageways are free of obstruction.

Continuation on 809C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JML BOARD & CARE
FACILITY NUMBER: 198600686
VISIT DATE: 05/09/2023
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LPA reviewed (4) client files, (3) employee files and conducted 2 staff interviews and 3 client interviews. LPA reviewed 4 client medications and review medication book. Administrator Certificate Expires: 11/30/23.
Clients are associated to Frank D. Lantherman Regional Center. LPA Calderon instructed Fierro on how to access Guardian to associate a staff member.

No deficiencies were issues and an exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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