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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602869
Report Date: 12/17/2024
Date Signed: 12/17/2024 01:46:19 PM

Document Has Been Signed on 12/17/2024 01:46 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:JJVITACARE1, INCFACILITY NUMBER:
198602869
ADMINISTRATOR/
DIRECTOR:
VITANGCOL, MYRABELFACILITY TYPE:
735
ADDRESS:21321 FOUNTAIN SPRINGS ROADTELEPHONE:
(909) 641-7109
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 6DATE:
12/17/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Maria Agustin, StaffTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA met with Administrator, Florentino Vitangcol. The initial visit was conducted on 12/10/24.

LPA conducted the remainder of the CARE tool domains during the visit today:
Staffing: There is sufficient staffing at the facility and an awake staff in the overnight shift. Staff are fingerprint cleared and associated to the facility.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed 3 personnel files and files are complete. Staff have current CPR/first aid training and sufficient on-going training. Administrator (Florentino Vitangcol) has the current HIV & TB certificate that was completed on 8/16/24.
Client Rights: Facility provides internet access to clients.
Client Records-Incident Reports: Client files are maintained at the facility. LPA reviewed all 6 client files and their files contain the required documentation such as the admission agreement, current IPP, medical assessment with TB results, consent forms, and safeguard of cash and inventory form.
Health-Related Services: Medications are centrally stored and locked in a dining room cabinet. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for 6 clients and meds are being administered as prescribed by the physician.
Incidental Medical & Dental: There is currently no client with a restricted or prohibited health condition.
Disaster Preparedness: The facility has the Emergency Disaster Plan accessible and reviewed annually. Disaster drills are conducted quarterly.
Emergency Intervention: Staff have CPI training but do not use manual restraints on clients.

There are no deficiencies issued today. An exit interview was held and a copy of this report was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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