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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602954
Report Date: 10/31/2023
Date Signed: 10/31/2023 03:49:15 PM

Document Has Been Signed on 10/31/2023 03:49 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:
10/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:House Manager Loida Samonte TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with House Manager Loida Samonte and the purpose of the visit was discussed. The following (10) of (12) (CARE) tool domains were utilized during the inspection:

Infection Control:
  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has an Infection Control Plan.

Operational Requirements:
  • A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan.
  • A fire clearance for four clients of which (0) may be non ambulatory; 0 may be bedridden.

Physical Plant/Environment Safety:
  • The facility is a single story home 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) client 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.
  • The physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents.
  • Fire Alarms were inspected. Fire extinguishers Observed
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JENESIS HOMES 2
FACILITY NUMBER: 198602954
VISIT DATE: 10/31/2023
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Client Records-Incident Reports:
  • A total of four (4) client files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment / IPPs, Physician's Orders, medical consent, and medication records.
  • Complaint poster and Personal rights were observed posted.

Client Rights-Information
  • No postural Supports Observed
  • Internet source provided to clients in care

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • An activity calendar was reviewed

Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies observed.
  • Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:
  • Four Client (4) centrally stored resident medications were reviewed.

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place.

Clients with Special Health Needs:
  • There are currently (4) Clients and none are on Hospice or Home Health
  • No half bed rails for mobility assistance were observed in rooms.
  • Individual Service Plans and Appraisals are on file.
  • No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, NO deficiencies were cited. LPA to return at a later date and complete the remaining CARE Tools Domains Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC809 (FAS) - (06/04)
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