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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601896
Report Date: 03/01/2022
Date Signed: 03/01/2022 04:22:12 PM

Document Has Been Signed on 03/01/2022 04:22 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:JIDDE RESIDENTIAL HOME IIFACILITY NUMBER:
198601896
ADMINISTRATOR:DEXTER DIZONFACILITY TYPE:
735
ADDRESS:3702 STEARNLEE AVENUETELEPHONE:
(562) 377-0102
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 4CENSUS: 4DATE:
03/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Andrew NacionTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced case management visit on 03/01/2022. The purpose of the visit was to serve the 'ORDER TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM FACILITY’ to Staff #1, and the 'ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY' to the Administrator Andrew Nacion

An investigation by the California Department of Social Services was conducted and it was determined that Staff #1 violated the personal rights of Clients #1. Government Code 11522 was also issued informing Staff #1 that an excluded person may petition for reinstatement to the Department no less than one year after the effective date of the exclusion order.



LPA Jordan delivered in person to the facility the immediate exclusion letter dated 03/01/22 for Staff #1 to Administrator Andrew Nacion

Government Code 11522 was also issued informing Staff #1 that an excluded person may petition for reinstatement to the Department no less than one year after the effective date of the exclusion order.


It should be noted that copies of the letters will be sent via mail and by certified mail to both parties.

Exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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