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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602183
Report Date: 02/09/2023
Date Signed: 02/10/2023 01:27:22 PM


Document Has Been Signed on 02/10/2023 01:27 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:JORDAN GUEST HOMEFACILITY NUMBER:
198602183
ADMINISTRATOR:BOHANAN, VILMA TRAZOFACILITY TYPE:
740
ADDRESS:10657 JORDAN ROADTELEPHONE:
(562) 822-4677
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:6CENSUS: 5DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator Vilma BohananTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Jose Villalobos made an unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Administrator Vilma Bohanan and the purpose of the visit was discussed.

As a part of the inspection, LPA used the inspection tool, reviewed (5) resident records, (4) staff files, and (5) resident medications. Currently the facility has (5) residents which are non-ambulatory. The two-story residential house consists of (4) resident bedrooms, (2) resident bathroom, living room, dining room, kitchen, 2nd floor is staff living quarters, covered patio with table and chairs, and a detached garage. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. Bedrooms #1-#2 are equipped with two beds, a dresser, lamp, chair, overhead lightning and closet space. Bedrooms #3 and #4 are single resident rooms with the required furniture as well. Bathrooms have a working toilet, wash basin, and showers. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies stored for each resident observed. Fire alarms are interconnected and operational. Required postings observed. There is (1) fire places blocked off from use. Backyard pool is gated and inaccessible to residents. Water temperature within required tittle 22 regulations.

Infection control domain completed and there were no deficiencies. An exit interview was conducted. Copy of this report provided Administrator Vilma Bohanan.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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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