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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600686
Report Date: 04/15/2025
Date Signed: 04/15/2025 02:22:36 PM

Document Has Been Signed on 04/15/2025 02:22 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:JML BOARD & CAREFACILITY NUMBER:
198600686
ADMINISTRATOR/
DIRECTOR:		FIERRO, GILBERTFACILITY TYPE:
735
ADDRESS:191 EAST WASHINGTON BLVD.TELEPHONE:
(626) 797-5022
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 4CENSUS: 3DATE:
04/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Gilbert Fierro - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Bennette Pena and Blanca Gonzalez conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Reynaldo Francisco, DSP I & II and explained the purpose of today's visit. Shortly after, Gilbert Fierro, Administrator arrived and assisted LPAs with the inspection. The facility is approved to serve developmentally disabled adults 18-59 years old, (4) ambulatory only. Facility is level 3 with services provided by Frank D. Lanterman Regional Center. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are adhering to infection control requirements. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Surety bond is in effect in the amount of $1000, expiring 12/04/2026. Fire Drill was last conducted on 01/03/2025. LPAs observed that (2) fire extinguishers in the premises expired on 03/21/2024 and needed to be serviced or replaced.
Physical Plant & Environment Safety: This facility is a single story home consists of (4) bedrooms, (1) staff room, (2) bathrooms, kitchen, dining room, living room, laundry area, backyard, detached garage and a shaded patio. Currently, there are (3) clients residing in the home. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. The window sill in bedroom #1 is damaged, rotting and has cracks. Smoke alarms and carbon monoxide were tested and operable. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 105.9 deg F in bathroom #1 and 106.8 deg F in bathroom #2. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area, but not outdoor furniture, chairs. No cameras in the facility.*****Refer to LIC 809C for the continuation of this report.*****
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: JML BOARD & CARE
FACILITY NUMBER: 198600686
VISIT DATE: 04/15/2025
NARRATIVE
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Staffing: A total of three (3) staff members including the Administrator provide care and supervision to the client. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator certificate is valid and will expire on 11/30/2025. File reviews show that there is no NOC shift staff assigned.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (3) staff files including the Administrator. Proof of staff training, health clearance, and vaccinations are current. Upon review, one of the staff has been cleared and associated in the facility via Guardian, however, staff did not have the required records/documents in the facility.
Client Rights-Information: Client personal rights are posted. Facility provides internet service and phone to the client.
Client Records-Incident Reports: LPA reviewed (3) client files. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. There is (1) client with with special diet residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas and locked in a cabinet.
Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for all (3) clients. 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 no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D and Technical Assistance issued. Exit interview, appeals rights and a copy of this report was provided to Administrator, Gilbert Fierro.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2025 02:22 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/15/2025 at 01:23 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: JML BOARD & CARE
FACILITY NUMBER: 198600686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that (2) fire extinguishers in the premises expired on 03/21/2024 and needed to be serviced or replaced which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 04/16/2025
Plan of Correction
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Administrator shall replace or have the fire extinguishers serviced immediately. Proof will be submitted to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2025 02:22 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/15/2025 at 01:23 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: JML BOARD & CARE
FACILITY NUMBER: 198600686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that the window sill in bedroom #1 is damaged, rotting and has cracks which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 04/22/2025
Plan of Correction
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Administrator to fix the broken window sill in bedroom #1 and submit photos/receipts that it's been fixed to CCL/LPA by POC due date.
Type B
Section Cited
CCR
85065.6(g)
Night Supervision
(g) In facilities providing care to Regional Center clients who rely upon others to perform all activities of daily living, night supervision shall be maintained as required by the Regional Center, but no less than the staff-client ratio specified in Sections 85065.6(f) and (f)(1).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the Administrator did not comply with the section cited above in that there's inadequate staff at night to perform duties to meet the needs of clients in care which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 04/18/2025
Plan of Correction
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Administrator shall ensure that there is adequate staffing day and night to meet the clients' needs and will send plan to fill the NOC shift staff to CCL/LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2025 02:22 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/15/2025 at 01:23 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: JML BOARD & CARE
FACILITY NUMBER: 198600686

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the Administrator did not comply with the section cited above in that one of the staff (S4) has been cleared and associated in the facility via Guardian, however, staff did not have the required records/documents in the facility which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 04/25/2025
Plan of Correction
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Administrator to ensure that personnel records for all employees are maintained in the facility and available for licensing to review. Administrator to submit all required staff files, training records for Staff #4 (S4) to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
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