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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603202
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:40:41 PM

Document Has Been Signed on 11/09/2022 02:40 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:JERICA'S HOMECAREFACILITY NUMBER:
198603202
ADMINISTRATOR:JAMES L. SANTIAGOFACILITY TYPE:
735
ADDRESS:633 E BASELINE RDTELEPHONE:
(909) 218-9356
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 2DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ibironke Duromole - DSPTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Ibironke Duromole (DSP) and explained the reason for the visit. Administrator James Santiago showed up shortly after. The facility is licensed to serve 4 ambulatory clients only ages 18-59. Facility currently has 2 ambulatory client serviced by San Gabriel/Pomona Regional Center.

A tour of the single-story facility included the living room, kitchen, 4 client bedrooms, 2 bathrooms, office, front yard, backyard, and attached garage. LPA Mora conducted the tour with Ibironke and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen and refrigerator in the garage. Sharps and cleaning chemicals were observed locked in the garage. The First Aid kit is kept locked in the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinets. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in the living room. Client and staff files are kept locked in the office. All bedrooms have all required furniture, lighting, and bedding. The bathrooms were observed with shower mats. The water temperature was tested in the both bathrooms and measured at 112.7 degrees F and 108.6 degrees F, which is not within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and it is fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. A carbon monoxide was observed in the kitchen and it was operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

LPA reviewed medication for both clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for both clients and 3 staff and observed no deficiencies. James Santiago has an administrator certificate - 6009182735 that expires on 12/28/23. (CONTINUED TO LIC 809C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: JERICA'S HOMECARE
FACILITY NUMBER: 198603202
VISIT DATE: 11/09/2022
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Facility has 30 days supplies of Personal Protective Equipment in the office. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
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