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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602183
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:03:33 PM


Document Has Been Signed on 02/27/2024 04:03 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:BOHANAN, VILMA TRAZOFACILITY TYPE:
740
ADDRESS:10657 JORDAN ROADTELEPHONE:
(562) 822-4677
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:6CENSUS: 5DATE:
02/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Vilma Bohanan, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with Administrator, Vilma Bohanan, and explained the purpose for the visit. The fire clearance is approved for (6) non-ambulatory residents, ages 60 and over, of which (1) may be bedridden. There is a hospice waiver approved for 4 residents.

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 wearing gloves while assisting residents. Staff are cleaning and disinfecting daily.
Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. The facility has the sufficient amount for liability insurance covering injury to residents and guests. Physical Plant & Environment Safety: The facility has a swimming pool in the backyard and is surrounded by a locked gate. There are 4 resident bedrooms downstairs, 1 staff room upstairs, 2 communal bathrooms, open living room, dining room, and kitchen. There is a detached garage with a rest area for staff. Facility has an operable smoke detector in each room and a carbon monoxide detector located in the hallway. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to residents. There are no firearms or weapons stored at the facility. The hot water temperature was measured within the required range of 105-120 degrees F. The fireplace is secured by a fence.
Staffing: Per Administrator, she had submitted documents to renew her certificate. LPA verified documents were received and is pending approval. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
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: JORDAN GUEST HOME
FACILITY NUMBER: 198602183
VISIT DATE: 02/27/2024
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Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid certificates.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights. However, Resident #4, who has dementia, does not have an updated physician's report.
Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed all 5 residents' medication and they are being administered as prescribed by the physician.
Disaster Preparedness: Facility has an updated Emergency Disaster Plan with contact numbers, at least 2 relocation sites, and emergency procedures.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training to care for residents with dementia and those on hospice.

Deficiencies are issued on the LIC809D form. Technical advisories were also provided. An exit interview was held. A copy of this report, technical advisory notes, and appeal rights were given to the Administrator.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 02/27/2024 04:03 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

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 which Resident #4 with dementia does not have the annual medical assessment which poses a potential health and safety risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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The licensee shall ensure that residents with dementia will obtain an annual medical assessment and a reappraisal done at least annually. Licensee shall submit the updated medical assessment for Resident #4 by POC due date of 3/12/24.
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician...

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 which staff #3 did not obtain a health screening and TB test which poses a potential health and safety risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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The licensee shall ensure all employee obtain a health screening including TB test done no more than 6 months prior or 7 days after employment. Licensee shall submit Staff #3's health screening with TB result by POC due date 3/12/24.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5