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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600789
Report Date: 09/14/2022
Date Signed: 12/22/2022 04:04:13 PM

Document Has Been Signed on 12/22/2022 04:04 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:JOMERT HOMEFACILITY NUMBER:
198600789
ADMINISTRATOR:MARIA PLISSFACILITY TYPE:
735
ADDRESS:13430 HARVEST AVETELEPHONE:
(562) 921-2378
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Maria Pliss TIME COMPLETED:
01:21 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted unannounced visit for the purpose of 1 year required infection control inspection. LPA was greeted at the door by caregiver Susan Robles and granted entry. Administrator Maria Pliss arrived a short time later. LPA discussed purpose of visit. LPA was informed by caregiver that there are currently four (4) clients residing at this facility.

LPA accompanied by caregiver Susan began the tour of the inside and outside of facility which is a one story home. The home consists of four (4) client bedrooms, one (1) staff room, two (2) bathrooms, a living room, dining room, kitchen, patio and a large backyard. The washer and dryer unit is located adjacent to the kitchen area. There is an unattached garage which is locked and not accessibility to clients. Fire clearance is maintained in conformity with State Fire Marshall regulations. There are no bodies of water of firearms at this location. Last fire drill was on 5/12/2022 and Administrator certificate expires on 12/17/2022


The following were observed/inspected:
· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· LPA was screened for this visit.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility does not have a designated isolation room as all the clients have private rooms
· Four client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Client rooms were not equipped with alcohol-based hand sanitizer but available throughout facility.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.

CONTINUED ON 809C.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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Document Has Been Signed on 12/22/2022 04:04 PM - It Cannot Be Edited


Created By: Alberto Lopez On 09/14/2022 at 12:41 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: JOMERT HOME
FACILITY NUMBER: 198600789

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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. Water in by staff room measured 102.6 degrees F, kitchen tested at 99 degrees F and Big restroom tested at 96 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Licensee will adjust water temperature and send proof to LPA by POC date.

****Licensee adjusted water temperature during visit, no further action is required****
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.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2022 04:04 PM - It Cannot Be Edited


Created By: Alberto Lopez On 09/14/2022 at 12:41 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: JOMERT HOME
FACILITY NUMBER: 198600789

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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. Two screens in client rooms are in need of repair or replacement which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Licensee will repair or replace window screens and send proof to LPA by POC 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.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


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: JOMERT HOME
FACILITY NUMBER: 198600789
VISIT DATE: 09/14/2022
NARRATIVE
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LPA and Caregiver Susan observed 2 screens that are in need of repair and hot water temperature was below 105 degrees F in two bathroom sinks and kitchen.

Deficiencies cited, please see 809D for details.

Exit interview conducted with Administrator Maria Pliss and copy of report provided

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC809 (FAS) - (06/04)
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