198602158-7-27-2024-28-AS-THEA-D7KPRC-20240727113230

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602158
Report Date: 07/27/2024
Date Signed: 07/27/2024 11:32:35 AM

Document Has Been Signed on 07/27/2024 11:32 AM - 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:	JENESIS HOME		FACILITY NUMBER:	198602158
ADMINISTRATOR/ DIRECTOR:	MOCLING, JOANN A.		FACILITY TYPE:	735
ADDRESS:	9921 SCRIBNER AVE		TELEPHONE:	(562) 944-1994
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90605
CAPACITY: 4		CENSUS: 4	DATE:	07/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Ellamea "Ella" Recla - Caregiver		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Ella Recla (Caregiver) and explained the reason for the visit, shortly after Administrator Joann Mocling arrived to assist with the visit. The facility is licensed to serve (4) Ambulatory Adults, ages 18 through 59. Facility currently has 4 Ambulatory clients serviced by Harbor Regional Center.

The facility is a single-story home located in a residential area in Whittier, Ca. A tour of the facility includes: living room, dining area, kitchen, staff office, 3 client bedrooms, 2 bathrooms (one is a staff bathroom), laundry area, attached garage, front yard and back yard with sectioned off locked area with a storage shed.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and was within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet in the garage and are inaccessible to clients, however, during tour LPA observed cleaning supplies stored in an unlocked cabinet in unlocked staff bathroom, cabinet in kitchen that holds cleaning supplies was also unlocked, details will be cited on the 809-D. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.

(Continued on LIC809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JENESIS HOME	FACILITY NUMBER: 198602158
	VISIT DATE: 07/27/2024

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Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has a shaded activity area, with tables and chairs stored in garage that are readily available for outdoor use. Last fire/earthquake drill was conducted on 7/1/24.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED/CPI and sufficient on-going training. Administrator Joann Mocling maintains a valid certificate that expired on 3/27/24 but was able to show proof of pending renewal LPA also checked CCL website and verified renewal with new expiration date of 3/27/2026.
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques, however, staff maintain valid CPI certificates in the case use is needed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during todays visit will be documented on the 809D.

Exit interview was held and a copy of the report was given to Administrator Joann Mocling.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/27/2024 11:32 AM - It Cannot Be Edited

Created By: Tena Herrera On 07/27/2024 at 11:17 AM

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: JENESIS HOME	FACILITY NUMBER: 198602158
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2024

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 as during tour LPA observed AJAX in an unlocked cabinet under bathroom sink within the unlocked staff bathroom, additionally the cleaning solutions under the kitchen sink were unlocked (staff stated it is because one staff is cleaning client bathroom, however, clients were awake and walking around facility including the kitchen) this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2024
	Plan of Correction
1 2 3 4	Staff immediatly removed the AJAX during tour, placed in cleaning supply cabinet and locked it Administrator/Licensee to hold a training for staff that covers proper storage of 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. A copy of the training materials and training log with participats to be emailed to LPA by 8/5/2024 (tena.herrera@dss.ca.gov).

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:

David Sicairos

LICENSING EVALUATOR NAME:

Tena Herrera

LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

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