<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601895
Report Date: 09/06/2024
Date Signed: 09/06/2024 04:05:55 PM

Document Has Been Signed on 09/06/2024 04:05 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:JIDDE RESIDENTIAL HOME IFACILITY NUMBER:
198601895
ADMINISTRATOR/
DIRECTOR:		DEXTER DIZONFACILITY TYPE:
735
ADDRESS:2680 CLARK AVETELEPHONE:
(562) 429-1401
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 4CENSUS: 4DATE:
09/06/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:43 PM
MET WITH:Julius Lopez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On September 6, 2024 Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced Case Management-Annual Continuation visit from August 29,2024 using the CARE Inspection Tool. LPA met with the Direct Service Professional (DSP) Monette Mendiola. Administrator Julius Lopez arrived and assisted with the visit. LPA explained the purpose of today’s visit. The facility is licensed to operate for four (4) ambulatory adults ages 18 through 59. The clients are Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) clients' rooms, two (2) bathrooms, a living area, a dining area, a kitchen, and an outside patio area.

During today's visit LPA reviewed resident's medications, reviewed residents' files, staff files, staff training's and resident's Personal and Incidental funds (P&I) records

Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked cabinet that is inaccessible to the residents in care.

Files LPA reviewed six (6) resident files and found they contained all the necessary documentation. LPA reviewed four (4) staff files and found they contained the required documentation, certification, and training's. LPA reviewed copies of Client Roster, Staff Roster, Emergency and Disaster Plan (LIC610E)

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: JIDDE RESIDENTIAL HOME I
FACILITY NUMBER: 198601895
VISIT DATE: 09/06/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed Residents' Personal and Incidental(P & I) records. LPA observed appropriate documentation of client funds are maintained in the facility.

LPA observed that all staff are cleared and associated to the facility. LPA observed that staff completed all required training (40-initial training). The Facility maintains ongoing staff training.

LPA did not observe any deficiencies during the time of visit.


An exit interview was conducted with Administrator Julius Lopez and a copy of this report was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2