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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602869
Report Date: 02/07/2023
Date Signed: 02/07/2023 11:13:06 AM

Document Has Been Signed on 02/07/2023 11:13 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:JJVITACARE1, INCFACILITY NUMBER:
198602869
ADMINISTRATOR:VITANGCOL, MYRABELFACILITY TYPE:
735
ADDRESS:21321 FOUNTAIN SPRINGS ROADTELEPHONE:
(909) 641-7109
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 6DATE:
02/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH: Forentino Vitangol, Administrator and Rosa Quintero DSP TIME COMPLETED:
11:19 AM
NARRATIVE
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Licensing Program Analyst (LPA) Lopez conducted an annual required visit focusing on infection control. LPA met with DSP Rosa Quintero who assisted with inspection and Administrator Florentino Vitangcol arrived about 68 minutes later and LPA explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications, and inspected food supply. The facility cares for developmentally disable adults and is vendorized by San Gabriel/Pomona Regional Center as a Level 4 home.

All client bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The client bathrooms have the required grabs bars and non-skid mat for non-ambulatory clients. The hot water was measured between 105.4 – 111.3 degrees which is within the required 105 - 120 degrees. Cleaning supplies are locked in the garage and inaccessible to clients. The kitchen was inspected. There is sufficient perishable and non-perishable food. There is additional food in the garage freezer. All the appliances are clean and seem to be operating properly. The common areas include the living room and dining area. These areas are clean and have the required furniture. The entrance of the home has sanitizer, PPEs and a thermometer. Staff document client temperatures daily and require visitors to sign in. Facility currently has at least a 30-day supply of PPEs.

Zero (0) staff records were reviewed. LPA reviewed 5 clients' medications. Medications are documented properly and are locked in a cabinet making them inaccessible to clients.

Per California Code of Regulations, Title 22, there were deficiencies observed during the visit. Please see 809D for details. Exit interview held. A copy of the report was provided to Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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 3
Document Has Been Signed on 02/07/2023 11:13 AM - It Cannot Be Edited


Created By: Alberto Lopez On 02/07/2023 at 10:23 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: JJVITACARE1, INC
FACILITY NUMBER: 198602869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed one wooden plank that was loose on back yard fence which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2023
Plan of Correction
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Administrator will repair the loose wooden plank and send proof to LPA by POC date.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed ladder, exercise bicycle, buckets and other items behind the strorage shed in back yard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2023
Plan of Correction
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Administrator will remove debris from back of the shed and send proof to LPA by POC 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/07/2023 11:13 AM - It Cannot Be Edited


Created By: Alberto Lopez On 02/07/2023 at 10:23 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: JJVITACARE1, INC
FACILITY NUMBER: 198602869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. One screen in the front of the home is in need of repair or replacement which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2023
Plan of Correction
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Administrator will repair or replace window screen and send proof to LPA by POC 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023


LIC809 (FAS) - (06/04)
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