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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601526
Report Date: 06/02/2023
Date Signed: 06/02/2023 04:12:32 PM

Document Has Been Signed on 06/02/2023 04:12 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:JULSTIN RESIDENTIAL CARE CENTERFACILITY NUMBER:
198601526
ADMINISTRATOR:OMAR SAPALARANFACILITY TYPE:
735
ADDRESS:2318 E. WALNUT CREEK PKWYTELEPHONE:
(626) 862-7207
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
06/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Omar Sapalaran TIME COMPLETED:
01:58 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong conducted a case management visit as a result of the deficiency that LPA during today's complaint visit.

On today's date, LPA observed two food containers in the refrigerator which labeled as Pear Broccoli Crunch Salad and funfetti cake but in the containers but it was shaded bell pepper and other food which licensee admitted they used the containers for food storage. In addition, while LPA inspected the canned good in the kitchen cabinet, LPA observed some insects were crawling on the canned good of tomato sauce and inside the kitchen cabinet too.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 1



Exit interview was conducted, appeals rights discussed and a copy was given to the administrator Omar Sapalaran.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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 06/02/2023 04:12 PM - It Cannot Be Edited


Created By: Christine Wong On 06/02/2023 at 02:10 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: JULSTIN RESIDENTIAL CARE CENTER
FACILITY NUMBER: 198601526

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2023
Section Cited
CCR
80076(a)(17)

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80076 Food Services (a) In facilities providing meals to clients, the following shall apply:(17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

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Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
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The requirement was not met as evidenced by: LPA observed insects were crawling on the canned good and kitchen cabinet which posed a potential risk to clients in care.
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Type B
06/09/2023
Section Cited
CCR80076(a)(18)

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80076 Food Services (a)In facilities providing meals to clients, the following shall apply: (18)All food shall be protected against contamination. Contaminated food shall be discarded immediately.
The requirement was not met as evidenced by:
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Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
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LPA's observation, LPA observed two containers in the refrigerator and the label on the two containers which does not match the food in the container which posed a potential 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:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023


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