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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602954
Report Date: 06/13/2022
Date Signed: 06/13/2022 02:41:19 PM

Document Has Been Signed on 06/13/2022 02:41 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JENESIS HOMES 2FACILITY NUMBER:
198602954
ADMINISTRATOR:MOCLING, JOANN AFACILITY TYPE:
735
ADDRESS:15019 ROSALITA DRIVETELEPHONE:
(714) 684-4972
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 4DATE:
06/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Manager Loida Samonte TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos made an unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Manager Loida Samonte and the purpose of the visit was discussed.

As a part of the inspection, LPA used the inspection tool, reviewed (4) client records, (3) staff files, and (4) client medications. Currently the facility has (4) clients which are ambulatory. The facility is vendorized through Eastern Los Angeles Regional Center. The facility is a single story building located in a residential area and contains the following: dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for sharps, (4) resident rooms, (2) bathrooms with shower, toilet and washbasin, and space for washer and dryer. Backyard also has a shaded area and seating for client use. There is an attached garage kept inaccessible to clients. The residence is equipped with central air and heating. Toxins and sharps locked and inaccessible to clients. Bedrooms #1-#4 are equipped with a bed each, a dresser, lamp, chair, overhead lightning and closet space. Bathrooms have a working toilet, wash basin, and showers. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies stored in each client's bedrooms were observed. Fire alarms are interconnected and operational. Required postings observed. Water temperature within required tittle 22 regulations.

Infection control domain completed and there were no deficiencies. An exit interview was conducted. Copy of this report provided to Manager Loida Samonte
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2022
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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