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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603387
Report Date: 02/09/2022
Date Signed: 02/09/2022 11:58:54 AM

Document Has Been Signed on 02/09/2022 11:58 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JMJ CAREFACILITY NUMBER:
198603387
ADMINISTRATOR:KIM, MOO JUNGFACILITY TYPE:
735
ADDRESS:1346 BALLISTA AVETELEPHONE:
(805) 259-6715
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 4CENSUS: 0DATE:
02/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Moo Kim TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual inspection. LPA met with the administrator Moo Kim and explained the reason of the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures and observed food supply. Facility has submitted a mitigation plan and was approved on 07/30/21.

Currently the facility has no client reside there. The facility is a one story house located at the residential neighborhood. The home consists of the living room, dining area, kitchen, office/entertainment area, four clients bedrooms and two bathrooms. The laundry area is located outside from the back yard. The front and back yard are well maintained and has a shaded area and sitting area for client to use. Each clients bedroom has one bed, one chair, one drawer, required linen and furniture and sufficient lighting and closet space. All two bathrooms are clean and sanitary and in good condition and have a working toilets, hand washing and shower are safe. All sharp utensils and knifes are locked in the kitchen cabinet. And all the poison, toxic and cleaning solutions were locked under the sink. LPA inspected the smoke detector and carbon monoxide and they are operable and in compliance. The hot water temperature was measured in the two bathrooms were between 115 and 116.9 degrees F. LPA also observed food supply is adequate and probably stored. Due to no client currently reside in the facility, there's no medication to be reviewed during the annual inspection but all the medication are centrally stored and they are locked in the medication cabinet next to the refrigerator. LPA also inspected the first aid kit and they are located in the medication cabinet and is inaccessible to client and have all required supplies.

No deficiencies issued under California Code of Regulations Title 22.

Exit interview conducted. A copy of the report was provided to Administrator Moo Kim
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
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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