198603426-8-7-2023-28-AS-JBAE-CUGR2G-20230807123819

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603426
Report Date: 08/07/2023
Date Signed: 08/07/2023 12:38:25 PM

Document Has Been Signed on 08/07/2023 12:38 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	J AND C HOUSE OF LOVE II		FACILITY NUMBER:	198603426
ADMINISTRATOR:	SMITH, CHANTE		FACILITY TYPE:	740
ADDRESS:	15218 WILDER AVENUE		TELEPHONE:	(562) 706-2128
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 5	DATE:	08/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Administrator Chante Smith		TIME COMPLETED:	12:52 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 8/07/23 at 9:47 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to J and C House of Love II. Upon arrival LPA was greeted by Direct Support Professional (DSP) Webit Getahun who contacted the Administrator, Chante Smith, at 9:50 a.m. LPA explained the reason for the visit to both staff and Administrator. This home is licensed to serve age range 60 and over: approved for (6) Ambulatory of which (6) maybe Non-ambulatory. Approved hospice waiver for (4). There were (5) residents in care during the time of this visit. The last emergency disaster/fire drill was conducted on 7/11/23. The Administrator Certificate expires on 10/08/2023 #6027733740. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (2) staff files, (5) resident files, medications, and medication administration records for (5) residents. This home contains 4 bedrooms,1 staff bedroom, 1 bathroom, living room, laundry room, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator, and observed all (4) resident bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The bathroom contained a working toilet, basin and water faucet, shower with grab bar, and shower chair. The temperature measured at 128.6*F, which is not within title 22 regulation. The smoke detectors were battery operated. tested and observed to be working properly. The carbon monoxide detector is located in the living room, tested, and functioning properly. There were (1) fire extinguishers located in kitchen fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans. The pantry was well stocked with canned goods, pasta, beans, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home. (Report continued on LIC809C.)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: J AND C HOUSE OF LOVE II	FACILITY NUMBER: 198603426
	VISIT DATE: 08/07/2023

NARRATIVE

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The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the clients.

The following Deficiencies were cited on the LIC809D under Title 22 California Code of Regulations Division 6, Chapter 1 & 6. Exit interview conducted with Chante Smith, Administrator, a copy of this report was provided, and Appeal rights given.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/07/2023 12:38 PM - It Cannot Be Edited

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: J AND C HOUSE OF LOVE II	FACILITY NUMBER: 198603426
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) (e) Water supplies and plumbing fixtures shall be maintined as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not lee than 105 (degrees F (41 degree C) and not more than 120 degrees F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1out of 1 bathrooms water temperature is at 128.6 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2023
	Plan of Correction
1 2 3 4	The facility will ensure water temperature is within title 22 regulations. The facility will keep a log for 5 days and send a copy to CCLD by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

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