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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602931
Report Date: 09/09/2024
Date Signed: 09/09/2024 11:35:11 AM

Document Has Been Signed on 09/09/2024 11:35 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:JOSHUA TREE HOMEFACILITY NUMBER:
198602931
ADMINISTRATOR/
DIRECTOR:
JASMIN TOMINESFACILITY TYPE:
735
ADDRESS:18207 VILLA CLARA STREETTELEPHONE:
(626) 295-2197
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 6DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:08 AM
MET WITH:Lolita Reyes - Direct Support StaffTIME VISIT/
INSPECTION COMPLETED:
11:49 AM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Lolita Reyes and explained the reason for the visit.

The facility is licensed to served 6 ambulatory adults ages 18 through 59, of which 2 may be non-ambulatory. Facility is located in a residential neighborhood and consist of a single home with 5 client bedrooms, 2 bathrooms, a living/dining room, kitchen, laundry area, storage area, an office, a front yard, and a back yard.

LPA Flores conducted a tour of the facility with Lolita Reyes and observed the following:
Facility is in good repair indoor and outdoor. Kitchen was observed clean. Food supplies were observed for at least 2 days worth of perishables and 7 days of non-perishables. Cleaning supplies and sharps were observed inaccessible to the clients during the visit. Medication cabinet was locked during the visit. Storage area hold additional food supplies and other supplies. Laundry area was clean and free of chemicals. Each client bedroom was observed clean with sufficient lighting, bedding supplies, and the required furniture. Bedroom #2 was observed to have a black burned outlet. Two bathrooms were observed clean, in good repair, and water temperature was tested between 107.6 - 107.8 degrees F., which is within the required 105-120 degrees F. Carbon Monoxide/Smoke detectors were tested and are in working condition. Fire extinguisher was observed. There are no large bodies of water in this home. Backyard has a covered seating area.
LPA reviewed 5 clients files, medication, P&I money, and 5 staff files.
A review of the facility's infection control plan, and emergency disaster plan was conducted.

A deficiency is noted during this visit under Title 22 Regulations.
Exit interview was conducted with Alvin Capanzana acting administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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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Document Has Been Signed on 09/09/2024 11:35 AM - It Cannot Be Edited


Created By: Mary G Flores On 09/09/2024 at 11:06 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: JOSHUA TREE HOME

FACILITY NUMBER: 198602931

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 09/09/2024

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 and interview, the licensee did not comply with the section cited above in power outlet in bedroom #2 was observed burned, per administrator it had sparked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Administrator will hire an electricitian to repair the outlet and ensure there will be no additional electrical burn outs and a picture of the repair and invoice of the repairs will be submtited to the department by POC due date 9/16/24.
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:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
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