198603312-1-7-2021-11-AS-UCOL-BX2ST8-20210107130907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603312
Report Date: 01/06/2021
Date Signed: 01/07/2021 01:10:28 PM

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	JAGS RESIDENTIAL CARE FOR THE ELDERLY		FACILITY NUMBER:	198603312
ADMINISTRATOR:	ENRIQUEZ, JALEEL		FACILITY TYPE:	740
ADDRESS:	1387 EAST 110TH STREET		TELEPHONE:	(323) 484-0171
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90059
CAPACITY:	6	CENSUS: 0	DATE:	01/06/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:03 AM
MET WITH:	Jaleel Enriquez		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On January 6, 2021 at 8:30 a.m., Licensing Program Analyst (LPA) Ulysses Coronel conducted an announced visit to the facility for purpose of a pre-licensing evaluation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre-licensing evaluation was conducted telephonically with applicant Jaleel Enriquez. An application was submitted to CCLD on 01/13/2020, for Initial license for a Residential Care Facility for the Elderly to serve the Elderly for 60 years and older. The requested capacity is for 6 of which 6 may be non-ambulatory and of which 0 may be bedridden. Structure: The facility is a 4-bedroom, 2-bathroom, single story house with a 2 car detached garage. The back yard has a sun shade, a table and chairs for clients. The passageways, walkways, driveways, steps and patios are free from obstructions. The front, back and side areas of free of hazards, such as ladders, gardening tools, motorized equipment. Bedrooms #1 and 3 are single occupancy bedrooms and bedrooms 2 and 4 are shared bedrooms. All four bedrooms have beds, chairs, nightstands and lamps in addition to overhead lighting and dressers/closets, which comply with the requirement of 8 cubic feet of space. Bedrooms Staff: There is none. Bathrooms: The bathrooms have a working toilet, wash basin, bathtub/shower. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in linen closet in bedroom hallway.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: JAGS RESIDENTIAL CARE FOR THE ELDERLY	FACILITY NUMBER: 198603312
	VISIT DATE: 01/06/2021

NARRATIVE

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Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review in the living room area. Fire Extinguisher located in the laudry area mounted on wall. The facilities telephone system is, landline.

Food Service: Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer next to the sink. Food supply stored in kitchen and consists of the following: 2 days supply on perishable and one weeks supply on nonperishable foods like meats, fruits, vegetables, rice, pastas, cereals, soups and sauces.

Smoke Detectors: Smoke and Carbon Monoxide combo units are installed in the kitchen, dining and living room areas, 4 bedrooms and Hallway are Electrical & connected.

Appliances: Stove burners, oven, microwave, refrigerator, washer, and dryer are in working condition. The residence is equipped with central air and heat.

Toxins: Locked/stored under the kitchen sink.

Water Temperature: Tested at 107.0 degrees Fahrenheit.

Medications, First-Aid Kit & Book: A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the office area, available for staff use but inaccessible to clients.

Clients & Staff Files: Records of staff and clients shall be stored in a locked cabinet in the office area and the section has been inspected along with the available records present.

Reading Material, Games, Equipment & Materials: The facility has board games, coloring books, and other recreational materials for the client's use, commensurate with the plan of operation.

Pool/Jacuzzi & Pets: None.

Fire clearance: Fire Clearance for up to 6 non-ambulatory residents and 0 bedridden was approved on 04/07/2020. Resident bedrooms do not have security bars. The exits do not have delayed egress, chain locks or dead bolts.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: JAGS RESIDENTIAL CARE FOR THE ELDERLY	FACILITY NUMBER: 198603312
	VISIT DATE: 01/06/2021

NARRATIVE

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The side patio gates do not have pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency.

Pre-licensing Checklist: Completed by licensee and reviewed by LPA.

Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to the applicant.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021

LIC809 (FAS) - (06/04)

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