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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602183
Report Date: 02/21/2025
Date Signed: 02/21/2025 12:48:48 PM

Document Has Been Signed on 02/21/2025 12:48 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:JORDAN GUEST HOMEFACILITY NUMBER:
198602183
ADMINISTRATOR/
DIRECTOR:		BOHANAN, VILMA TRAZOFACILITY TYPE:
740
ADDRESS:10657 JORDAN ROADTELEPHONE:
(562) 822-4677
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
02/21/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Vilma Bohanan - Administrator TIME VISIT/
INSPECTION COMPLETED:
01:03 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent unannounced Required 1-year annual continuation visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools to complete the annual inspection that was initially conducted on 2/11/2025. LPA met with Vilma Bohanan, administrator for the facility, and was granted entrance. There are five (5) residents residing within the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices were observed.


· Infection control plan is on file.

Physical Plant/Environment Safety:

· The facility is a two-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, six (6) of which may be non-ambulatory, one (1) of which may be bedridden, and a hospice waiver approved for four (4) residents. The facility consists of a kitchen, a dining room, a living room, a laundry room, one (1) staff bedroom, four (4) resident bedrooms, two (2) bathrooms, and a back yard with pool area. The facility was observed to be in good repair.


· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has two (2) fully charged fire extinguishers in the facility.
· Water temperature readings for one of the bathrooms in the home fell within the required range of 105 - 120 degrees Fahrenheit.
David SicairosTELEPHONE: (323) 981-3982
Erik ZaragozaTELEPHONE: (323) 981-3983
DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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 5
Document Has Been Signed on 02/21/2025 12:48 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 02/21/2025 at 12:20 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: JORDAN GUEST HOME
FACILITY NUMBER: 198602183

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 residents, becuase one client did not have a complete physician's report for section 13 on the LIC602A, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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Administrator is to ensure that all physician reports are completed at all times. Administrator is to complete the physicians report and email to LPA by the POC due date.
Type B
Section Cited
CCR
87457(c)(1)(A)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 residents, because 2 did not have complete pre-admission appraisals, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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Administrator is to ensure that pre-admission appraisals are conducted for all clients prior to admission. Administrator is to complete the pre-admission appraisals for the 2 clients and submit the to the LPA by the POC due date.
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
TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME:Erik Zaragoza
TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/21/2025 12:48 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 02/21/2025 at 12:20 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: JORDAN GUEST HOME
FACILITY NUMBER: 198602183

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 residents, because their appraisals had not been updated within the past year, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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Administrator is to ensure that reappraisals are conducted for all residents every year. Administrator is to conduct a reappraisal for the 3 residents and email the appraisals to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME:Erik Zaragoza
TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


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: JORDAN GUEST HOME
FACILITY NUMBER: 198602183
VISIT DATE: 02/21/2025
NARRATIVE
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Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, six (6) of which may be non-ambulatory, one (1) of which may be bedridden, and a hospice waiver approved for four (4) residents.


· Care and supervision to meet the clients’ needs was observed.

Staffing:

· Five (5) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Five (5) staff files were reviewed for criminal background clearance and training.


· All staff records reviewed have health a health screening with a Tuberculosis clearance, and all staff have First Aid/CPR trainings that are active.
· The administrator’s certificate expires on 6/3/2026.

Resident Rights/Information:

· Physician orders were reviewed for five (5) resident files.

· Medications were also reviewed for five (5) residents.

Resident Records/Incident Reports:

· Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.


· Two (2) residents did not have a completed Pre-Placement Appraisal on file.
· Three (3) residents did not have a Reappraisal conducted within the past year.
· One (1) resident did not have a completed Physician’s Report (LIC602A) in section thirteen (13).
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: JORDAN GUEST HOME
FACILITY NUMBER: 198602183
VISIT DATE: 02/21/2025
NARRATIVE
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 Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Incident Medical and Dental:

· Staff training was on file.

Disaster Preparedness:

· Emergency and Disaster Plan was publicly posted within the facility.

· The last emergency and disaster drill was conducted in January of 2025.

Planned Activities:

· Sufficient Space is provided to accommodate both indoor and outdoor activities.

· Sufficient equipment and supplies are provided to meet the requirements of the activity program.

Residents with Special Health Care Needs:

· There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds pages. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC809 (FAS) - (06/04)
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