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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600789
Report Date: 11/07/2023
Date Signed: 11/08/2023 12:08:19 PM

Document Has Been Signed on 11/08/2023 12:08 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:JOMERT HOMEFACILITY NUMBER:
198600789
ADMINISTRATOR:MARIA PLISSFACILITY TYPE:
735
ADDRESS:13430 HARVEST AVETELEPHONE:
(562) 921-2378
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 3DATE:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Maria PlissTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Required 1 year inspection at the facility and met with Administrator Maria Tina Pliss and explained the purpose for todays visit. The facility phone number is 562 868 7610.

The facility consist of 4 bedrooms, 1 staff room, 2 bathrooms, living room, dining room, kitchen, laundry area next to kitchen and a detached garage.

The facility had all postings at the front entrance, bathrooms, and throughout the facility. A Pre screening area with PPE supplies was observed upon entry into the facility.

LPA conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed fire extinguisher in the kitchen. The water temperature was tested and measured at 114 degrees F.
Administrators certificate for Maria Pliss #6009097735 expires 12/17/2024.

The following deficiencies were cited according to the tile 22 regulations. Appeal rights given.

Exit interview conducted.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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Document Has Been Signed on 11/08/2023 12:08 PM - It Cannot Be Edited


Created By: Nicol Wesley On 11/07/2023 at 12:31 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: 11/07/2023

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 licensee did not comply with the section cited above and the walls and floor boards in the facility were scratched, painted over, and had tape in order to paint over them, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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The licensee will ensure to have the items repaired by POC date 12/07/23.
Type B
Section Cited
CCR
80088(f)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents.

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 and all of the trash cans did not have convered lids on them, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2023
Plan of Correction
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The administrator shall have these items provided by POC date 11/21/2023.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Nicol Wesley
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
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