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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603312
Report Date: 03/09/2022
Date Signed: 03/09/2022 03:57:36 PM


Document Has Been Signed on 03/09/2022 03:57 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 DR #100
MONTERY PARK, CA 91754



FACILITY NAME:JAGS RESIDENTIAL CARE FACILITY FOR THE ELDERLYFACILITY NUMBER:
198603312
ADMINISTRATOR:ENRIQUEZ, JALEELFACILITY TYPE:
740
ADDRESS:1387 EAST 110TH STREETTELEPHONE:
(323) 244-1702
CITY:LOS ANGELESSTATE: CAZIP CODE:
90059
CAPACITY:6CENSUS: 0DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Gilda EnriquezTIME COMPLETED:
04:14 PM
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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas met with facility representative, Gilda Enriquez and conducted a risk assessment, based on the assessment, the facility is clear of Covid-19 infection. LPA explained the purpose of todays visit. The facility is licensed for six (6) residents age range 60 and over, six non-ambulatory, no hospice waiver. There are currently zero (0) residents in placement at this time.

LPA and Gilda both toured the inside and outside grounds of the facility. The one story residential house consists of four resident bedrooms, two (2) bathrooms, living room, Kitchen, Dining area and laundry area, 2 car detached garage. and shaded backyard area.

During the tour, LPA observed the facility’s infection control practices. LPA verified that the facility has an approved mitigation plan report. LPA explained proper visitor screening for Covid-19 symptoms, temperature shall be checked and documented on a log. LPA observed a sanitizing station at the facility entrance; PPE supplies are readily available and an additional 60 day supply of PPE is available. Sufficient paper, cleaning, and disinfecting supplies were observed. LPA observed Gilda wear a face covering. LPA observed required postings throughout the facility. CCLD PINS not available at this time.

All rooms were inspected, Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Resident bathrooms were checked, sufficient liquid soap observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, the water temperature measured at 130 degrees F in bathroom#2. Comfortable temperature was maintained in the facility.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: JAGS RESIDENTIAL CARE FACILITY FOR THE ELDERLY
FACILITY NUMBER: 198603312
VISIT DATE: 03/09/2022
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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage closet space. Centrally stored medications to be stored and inaccessible in large standing cabinet near dinning area. Dual/ interconnected Carbon Monoxide/ smoke detectors were tested, and in operating condition. The facility has Fire Extinguisher, which was checked and found to be fully charged, accessible, receipt has purchased date of 3/08/2022. The First Aid kit was available and fully stocked. There are no security bars or weapons on the premises.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions. No bodies of water present.

Advisory Notes with technical assistance were issued:

1. Facility doesn’t have a working land line, ensure service is available.

2. Bathroom water temperature measured 130 degree F, ensure heater is turned down.

3. Bedroom#4 has electric plate hanging and electric wiring exposed

4. LPA observed accessible gardening tools in the backyard.

5. CCLD Provider informatin notices (PINS) shall be printed and made available to residents/ and staff

6. Ensure upon hire staff is fit tested for respirators such as N95.

7. Ensure mitigation plan is reviewed/ shared with staff to ensure procedures are being followed.

8. Garage is not locked and LPA observed accessible bucket of paint.

An exit interview was conducted, and a copy of this report to be provided to facility representative. No deficiencies were cited during this visit.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC809 (FAS) - (06/04)
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