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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602570
Report Date: 08/11/2023
Date Signed: 08/14/2023 08:07:36 AM

Document Has Been Signed on 08/14/2023 08:07 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:JRC PLATINUM CARE HOMEFACILITY NUMBER:
198602570
ADMINISTRATOR:CANONES, JUNELLEFACILITY TYPE:
735
ADDRESS:2929 VAMANA STREETTELEPHONE:
(909) 279-5485
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 4DATE:
08/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Rizalina Gaeta/S-1TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Rizalina Gaeta/S-1 and discussed the purpose of today’s visit.

This home consists of 4 bedrooms, 2 bathrooms, living room. kitchen and dining room. All clients receive case management services provided by San Gabriel Pomona Regional Center. Fire Clearance is for (4) ambulatory clients.

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

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Operational Requirements: Last Disaster Drill was conducted on 02/10/23. Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms were tested and operable. Carbon monoxide detector was tested and is operable. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Water temperature measured at: 114.5* in bathroom between bedroom #1 and bedroom #2 and 113.9* in the hallway bathroom.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023
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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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: JRC PLATINUM CARE HOME
FACILITY NUMBER: 198602570
VISIT DATE: 08/11/2023
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Staffing: There is sufficient staffing at the facility. Administrator Certificate for Junelle Canones expires 08/21/23. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Deficiency cited as staff files were not on premises.

Client Rights-Information: Client rights are posted and included in Client files. Per S-1, there are no clients using postural supports.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #4 (C-4). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, Individual Program Plan (IPP), House Rules, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and bubbled packed. LPA reviewed medication for C-1 through C-4. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: There are (2) clients with restricted health condition plan (C-3 and C-4).

Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610D/9 pages) in place.

Deficiency cited. Refer to LIC 809D.

Exit interview, appeals rights and a copy of this report was provided to Rizalina Gaeta/S-1
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2023 08:07 AM - It Cannot Be Edited


Created By: Elizabeth Irra On 08/11/2023 at 10:19 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: JRC PLATINUM CARE HOME
FACILITY NUMBER: 198602570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
80066 (e) Personnel Records (e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA was unable to review staff files. Per Administrator (communicated via telephone), the staff files are not on premises as she is in the process of reviewing and updating the files.
POC Due Date: 08/14/2023
Plan of Correction
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Administrator to submit a written statement as to how Administrator will comply with this regulation and submit to LPA Irra by 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:Tony Vasallo
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023


LIC809 (FAS) - (06/04)
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