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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600686
Report Date: 03/26/2024
Date Signed: 03/26/2024 12:14:36 PM

Document Has Been Signed on 03/26/2024 12:14 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:FIERRO, GILBERTFACILITY TYPE:
735
ADDRESS:191 EAST WASHINGTON BLVD.TELEPHONE:
(626) 797-5022
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 4CENSUS: 3DATE:
03/26/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Reynaldo Francisco - Direct Support Professional I & IITIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent visit for annual continuation. LPA met with Reynaldo Francisco/Direct Support Professional I & II (DSP I & II) and explained the reason for the visit. LPA spoke with Administrator Gilbert Fierro on the phone and was told that he will not be able to come to the facility. The initial required-1 yr inspection was conducted on 03/14/2024. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools today for the remaining domains and observed the following:

Operational Requirements: A current Plan of Operation was reviewed. A fire clearance for four (4) ambulatory clients is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid and will expire on 07/15/2024. Surety Bond is in effect and in force with bond amount of $1000. Administrator stated that the fire drill was last conducted with staff in March 17, 2024.
Staffing: A total of five (5) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate has expired but recertification was submitted to CCL. Administrator has the proof of HIV training at the time of visit.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. DSP Francisco stated that no clients have their own personal cell phone and IPad/laptop. LPA interviewed (2) clients, as the other one was out in the Day Program.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There is one (1) client residing at this facility with special diet due to his medical condition. 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.
Client Records-Incident Reports: LPA reviewed Client files for C1 through Client 3. Client files are maintained at the facility. Records reviewed showed that (2) out of (3) clients in care are over 59 years old and an exception letter has not been requested. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C3. Facility uses Medication Administration Records (MARs). LPA observed that MARs were not documented properly. Medications are bubbled packed.
Incidental Medical Services: 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. Exit interview, appeals rights and a copy of this report was provided to the Reynaldo Francisco, Direct Support Professional I & II.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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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Document Has Been Signed on 03/26/2024 12:14 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/26/2024 at 10:54 AM
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: 03/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2024
Section Cited
CCR
85095.5(c)

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85095.5 Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.
This requirement is not met as evidenced by:
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Prior to the subsequent annual continuation visit, Licensee agreed to complete LIC9282. Licensee submitted a completed Infection Control Plan to LPA on 03/21/2024.
*****DEFICIENCY CLEARED*****
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Based on interview, record review, the licensee did not comply with the section cited above in that the Licensee has not developed, completed and submitted the required Infection Control Plan (LIC9282) which poses/posed a potential health, safety or personal rights risk to clients in care
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Type B
04/09/2024
Section Cited
CCR80087(a)(1)

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80087 Buildings 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....(1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement is not met as evidenced by:
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Prior to the subsequent annual continuation visit, Licensee agreed to fix the window screens. Licensee submitted photos of the fixed windown screens to LPA on 03/21/2024.
*****DEFICIENCY CLEARED*****
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Based on observation, LPA observed broken/ripped window screens in (2) client windows.
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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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/26/2024 12:14 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/26/2024 at 11:01 AM
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: 03/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/26/2024
Section Cited
CCR
80087(g)(1)

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80087 Buildings and Grounds....g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients....(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidenced by:
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Prior to subsequent continuation annual visit, the staff took the cleaning solution out immediately and stored it in a locked cabinet.
*****DEFICIENCY CLEARED*****
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Based on observation, the licensee did not comply with the section cited above in that LPA observed a spray cleaning solution in an unlocked cabinet by the laundry area which poses/posed a potential health, safety or personal rights risk to clients in care.
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Type A
03/20/2024
Section Cited
CCR80075(b)

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80075 Health Related Services ..(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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Licensee will re-train staff on proper medication documentation to avoid errors. Licensee to submit in-service training sheet signed by staff to CCL/LPA by POC due date.
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Based on interview, record review, the licensee did not comply with the section cited above in that the medications on 03/26/2024 were administered to C1/C2 but the staff did not properly record (5) a.m. medications for C1 and (1) a.m. medication for C2 on Medication Administration Records (MARs) which poses an immediate health, safety or personal rights risk to clients in care.
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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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/26/2024 12:14 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/26/2024 at 11:44 AM
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: 03/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2024
Section Cited
CCR
85068.4(g)

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85068.4 Acceptance and Retention Limitations..(g) If acceptance or retention of an individual 60 years of age or older ...exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, ..... the licensee must request an exception in order to accept or retain the individual.... The documentation specified in Section 85068.4(c) must be submitted with the exception request.

This requirement is not met as evidenced by:
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Licensee will send an exception request letter for (2) clients who are currently residing in the facility. Request letter along with other information will be emailed to LPA Pena on or before the POC due date.

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Based on record review, the licensee did not comply with the section cited above in which (2) out of (3) clients in care are over 59 years old which poses/posed a potential health, safety or personal rights risk to clients in care.
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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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024


LIC809 (FAS) - (06/04)
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