198600789-8-12-2024-28-AS-TRES-D83VEW-20240812162302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600789
Report Date: 08/12/2024
Date Signed: 08/12/2024 04:24:05 PM

Document Has Been Signed on 08/12/2024 04:24 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	JOMERT HOME		FACILITY NUMBER:	198600789
ADMINISTRATOR/ DIRECTOR:	MARIA PLISS		FACILITY TYPE:	735
ADDRESS:	13430 HARVEST AVE		TELEPHONE:	5629212378
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 4		CENSUS: 4	DATE:	08/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:49 PM
MET WITH:	Maria Pliss Licensee/Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tyler Reyes conducted an unannounced Required 1 year inspection at the facility and met with Licensee/Administrator Maria Pliss and explained the purpose for todays visit. The facility is licensed to serve four (4) Developmentally Disabled Adults ages 18-59. Two (2) Non-Ambulatory.

The facility is a snigle story home consisting of four (4) bedrooms, one (1) staff room, (2) bathrooms, living room, dining room, kitchen, laundry area, a detached garage, and a front and backyard. There are no bodies of water at this location. Last Emergency Disaster Drill was on 7/17/24 and Administrator Maria
Certificate expires 12/17/24.

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.
· Four client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.

. Five (5) staff files were reviewed -criminal record clearance, current first aid, CPR and CPI. Staff files are maintained at the facility and kept in a secured location..

. Four (4) clients files were reviewed -Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.

CONTINUED ON 809C.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JOMERT HOME	FACILITY NUMBER: 198600789
	VISIT DATE: 08/12/2024

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LPA Reyes observed with Licensee Maria a bottle of Purex Oxi Liquid Detergent,Downy fabric softener, and Clorox.These three items were observed on the floor nearest to the washer and dryer. LPA observed these cleaning products while 3 clients were present in the facility.LPA Reyes observed on the window seal of the laundry area with Licensee Maria a Spray n' Wash Max.

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

Exit interview conducted.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/12/2024 04:24 PM - It Cannot Be Edited

Created By: Tyler Reyes On 08/12/2024 at 04:07 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: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above LPA Reyes observed with Licensee Maria a bottle of Purex Oxi Liquid Detergent, Downy fabric softener, and Clorox.These three items were observed on the floor nearest to the washer and dryer. LPA observed these cleaning products while 3 clients were present in the facility.LPA Reyes observed on the window seal of the laundry area with Licensee Maria a Spray n' Wash Max.
	POC Due Date: 08/13/2024
	Plan of Correction
1 2 3 4	Licensee/Adminstrator Maria removed the disinfectants, and cleaning solutions and placed them in a secure location. Licensee will ensure that all disinfectants, cleaning solutions, poisons, and other items that could pose a danger to clients shall be inaccessible, and not handled by clients. CLEARED DURING VISIT

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Fernando Fierros

LICENSING EVALUATOR NAME:

Tyler Reyes

LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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