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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603477
Report Date: 09/22/2023
Date Signed: 09/25/2023 07:02:17 AM

Document Has Been Signed on 09/25/2023 07:02 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
GREATER LA AC/SC, 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: 4DATE:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:40 AM
MET WITH:Blessing Irhya and Ronel CanonesTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Blessing Irhya/S-1 and discussed the purpose of today’s visit. Ronel Canones arrived at approximately 9:00 A.M..

This is a single story home with 4 bedrooms, 2 full-bathrooms and 1 (1/2) bathroom, living room, kitchen, dining area, office and laundry room. The home has a detached garage. San Gabriel Pomona Regional Center provides case management services for all (4) clients residing at this facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Facility has an Infection Control Plan in place.

Operational Requirements: Last Disaster Drill was conducted on 06/02/23. Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms and carbon monoxide detectors were tested and are operable. Fire extinguisher observed (last serviced 03/15/23. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Water temperature measured as follows: 108.5*

Staffing: There is sufficient staffing at the facility. Administrator Certificate on file for Ronel Canones expires on 06/28/2023. Staff employed are over the age of 18 and are fingerprint cleared.

Personnel Records-Training: LPA reviewed staff files for Staff #1 (S-1) and Staff #5 (S-5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.

***Refer to LIC 809C for the continuation of this report**
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JRC TITANIUM CARE HOME INC.
FACILITY NUMBER: 198603477
VISIT DATE: 09/22/2023
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Client Rights-Information: Client rights are posted and included in Client files.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #4 (C-4).

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. There is an additional freezer with food supply in the kitchen. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin.

Health Related Services: The medications are centrally stored inside a locked locker near the dining area. The facility uses the Medication Administration Record (MAR) log to document medications given.

Incidental Medical Services: C-3 has a restricted health condition plan in place.

Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610D/9 pages) in place.
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Exit interview, appeals rights and a copy of this report was provided to Ronel Canones.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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