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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603202
Report Date: 11/12/2024
Date Signed: 11/12/2024 11:35:26 AM

Document Has Been Signed on 11/12/2024 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:JERICA'S HOMECARE, INC.FACILITY NUMBER:
198603202
ADMINISTRATOR/
DIRECTOR:		ACERO, MAUREEN JERICAFACILITY TYPE:
735
ADDRESS:633 E BASELINE RDTELEPHONE:
(909) 271-1657
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 4CENSUS: 4DATE:
11/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:33 AM
MET WITH:Maureen Jerica AceroTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by Direct Support Staff. Administrator Maureen Jerica Acero, arrived shortly after to assist with tour. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single story dwelling.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to clients, were observed to be inaccessible to clients. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) client rooms. All client bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near showers and toilets. During inspection, LPA Ramirez observed three (3) out of four (4) light bulbs to be inoperable in bathroom #1. LPA Ramirez observed two (2) out of three (3) light bulbs to be inoperable in bathroom#2. Staff replaced bulbs during inspection.

Food Service: LPA Ramirez observed sufficient supply of nonperishable for one week. LPA Ramirez did not observe staple of fresh perishable foods for a minimum of two days, however, staff delivered fresh perishables during inspection. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C).

Infection Control: Staff is using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.



Operational Requirements: The facility is licensed serve four (4) developmentally disabled clients 18-59 years old. The facility is a level VI G home and may care for four (4) ambulatory clients. All clients in the home receive services from San Gabriel/Pomona Regional Center.

SEE 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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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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, INC.
FACILITY NUMBER: 198603202
VISIT DATE: 11/12/2024
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Emergency Intervention: Facility staff are trained in Crisis Prevention & Intervention Training. Facility staff do not foresee the future use manual restraints or have a seclusion room in the facility.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last emergency drills were conducted on 03/20/24. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in garage.

Health Related Services/Incidental Medical Services: The medications are centrally stored and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services.

Staffing: Administrator Certificate for Maureen Jerica Acero is pending renewal. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.


Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid, and Crisis Prevention Intervention (CPI) for three (3) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed.

Client Records/Incident Reports: LPA reviewed client records for four (4) clients in care. Client records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Individual Program Plan (IPP), and Resident Rights were observed. All clients receive services from San Gabriel/Pomona Regional Center.



One (1) violation was observed during visit. Exit interview conducted. A copy of this report, 809-D, LIC 9120, and appeals rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/12/2024 11:35 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 11/12/2024 at 10:46 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: JERICA'S HOMECARE, INC.
FACILITY NUMBER: 198603202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, last documented drill was conducted in March of 2024, the licensee did not comply with the section cited above in 4 out of 4 clients, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2024
Plan of Correction
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Licensee will conduct drill and document drill by 11/26/24. Licensee will provide proof of drill by 11/26/24 to LPA Ramirez via email.
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:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
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