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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600947
Report Date: 04/25/2022
Date Signed: 04/25/2022 04:06:04 PM

Document Has Been Signed on 04/25/2022 04:06 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:JAMERIKA HOME CARE, INC.FACILITY NUMBER:
198600947
ADMINISTRATOR:FERRER, AMALIA A.FACILITY TYPE:
735
ADDRESS:5025 BURNABY DRIVETELEPHONE:
(626) 732-2912
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: 5DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Napoleon Ferrer, Staff
Pastora Ferrer, Staff		TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Direct Support Professionals (DSPs) Napoleon Ferrer and Pastora Ferrer, both assisted with the visit. The facility is licensed to serve six (6) Developmentally Disabled clients, (age 18-59), and approved for non-ambulatory clients. Facility licensing fees are current.

The facility is a single story home located in a residential neighborhood. The facility consisted of four (4) client bedrooms, staff bedroom, two (2) bathrooms, living room, dining room, kitchen, garage with laundry area and an indoor/outdoor activity area. Adequate linen and personal hygiene supply are observed. Bathrooms are clean and operable. Facility maintains the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms have beds, dresser and closet space available. Lamps/lights for each room are available to ensure the safety and comfort of all persons in the facility. Carbon monoxide detectors and smoke detectors are operable. Hot water temperature measured at 118.1 degrees Fahrenheit. Medications are centrally stored and locked. Medications were properly logged and current. Hazardous items are locked and inaccessible to clients. Fire extinguishers are fully charged and last services is 01/03/22. Last disaster drill is conducted 03/28/22. Facility has no bodies of water. Pesticides /poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils are stored.
No deficiencies were observed per Title 22 Regulation during the visit.

An exit interview was conducted. This report was discussed and provided to DSP, Napoleon Ferrer, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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