<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603477
Report Date: 09/02/2021
Date Signed: 09/02/2021 11:57:12 AM

Document Has Been Signed on 09/02/2021 11:57 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:JRC TITANIUM CARE HOME INC.FACILITY NUMBER:
198603477
ADMINISTRATOR:CANONES, RONELFACILITY TYPE:
735
ADDRESS:212 E LA VERNE AVETELEPHONE:
(909) 279-5485
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 0DATE:
09/02/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Applicant/Co-ApplicantTIME COMPLETED:
12:15 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
Licensing Program Analyst (LPA) Elizabeth Irra conducted a pre-licensing visit and met with Applicant and Co-Applicant. This facility is to serve 4 ambulatory individuals age 18 through 59 years old. Component III was also completed during this visit.

This is a single story home with 4 bedrooms, 2 full-bathrooms and 1 half bathroom, living room, kitchen, dinning area, office and laundry room. The home has a detached garage.



The following was observed/inspected:
  • Smoke detectors operate properly.
  • Carbon monoxide detector was tested and operable. It is located near the office.
  • Fire extinguisher located in the kitchen and laundry. Service date: 05/13/2021
  • Cleaning solutions are locked inside a cabinet located in the laundry room. Sharps are locked under the kitchen.
  • Building and grounds are free from hazards.
  • Beds have the required linen/supplies.
  • Mattresses and bedsprings are in good repair.
  • Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture.
  • Clients have the appropriate furniture (one chair, night stand, adequate lighting for each client adequate closet and drawer space).
  • There are enough bath towels, hand towels and wash cloths for all clients.
  • Sufficient amount of personal hygiene supplies are available for clients.


***Refer to LIC 809C for the continuation of this report***
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: JRC TITANIUM CARE HOME INC.
FACILITY NUMBER: 198603477
VISIT DATE: 09/02/2021
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
26
27
28
29
30
31
32
  • There are sufficient amount of linens available to permit weekly changing to ensure use of clean linens at all times by clients. There are extra supplies inside each bedroom.
  • Facility has a washer and dryer that are fully operational located in the laundry room.
  • Pantry's cupboards, freezers, stoves, microwaves, refrigerator and counters are clean.
  • Two day supply of perishables available, seven day supply of non-perishable available. Additional emergency food and water supply are stored inside the garage.
  • The facility has sufficient dinning tables and chairs.
  • Pesticides and other toxic substances are stored and locked inside the laundry room cabinet.
  • Client files (including P&I) and staff files will be locked inside the office. Medication will also be stored and locked inside the office.
  • First Aid Kit inspected. American Heart Associated First Aid Manual observed.
  • Physical plant is in good repair.
  • Building and grounds are free from hazards.
  • Window screens are in good repair and windows/curtains/blinds are in good repair and operate properly.
  • Outdoors: there is a shades area set up in the backyard to accommodate (4) clients.
  • Refrigerator, stove, telephone, sinks, tubs, toilets and showers operate properly.
  • Hot water temperature measured at 107.5* in the kitchen sink and all bathrooms.
  • Personal rights are posted.
  • Emergency Disaster Plan posted.
  • Complaint Procedures posted.
  • COVID-19 signs are posted throughout the facility including the entry door.

Pre-Licensing is complete and this facility has no deficiencies. Exit interview conducted, copy of report provided to Applicant.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2