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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603713
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:39:00 PM

Document Has Been Signed on 03/11/2025 04:39 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JAY & JESS GROUP HOME LLCFACILITY NUMBER:
198603713
ADMINISTRATOR/
DIRECTOR:		TOMINES, OLIVIAFACILITY TYPE:
735
ADDRESS:751 FULTON AVETELEPHONE:
(909) 306-4692
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91755
CAPACITY: 4CENSUS: 4DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:49 AM
MET WITH:Jeanybave Silvosa, Staff and Olivia Tomines, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:41 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted the required unannounced annual inspection. LPA met with Jeanybave Silvosa, Staff and explained the reason for the visit. The facility is licensed to serve 4 Ambulatory Developmentally Disabled Adults ages 18-59. Facility currently has 4 Ambulatory clients serviced by Eastern Los Angeles Regional Center.
The facility is a single-story home located in a residential area in Monterey Park, Ca. A tour of the facility includes living room, office space, dining area, kitchen, 3 bedrooms, 2 bathrooms, detached garage, front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and were not within the required range of 105.0 – 120.0 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. (continued on 809-C)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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: JAY & JESS GROUP HOME LLC
FACILITY NUMBER: 198603713
VISIT DATE: 03/11/2025
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Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was on date not known
Staffing: There appears to always be sufficient staffing in the facility. With night staff trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location within the facility. LPA reviewed 3 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, Current First Aid/CPR/AED and sufficient on-going training. Administrator Olivia Tomines Certificate expires on 3/11/25.Renewal was sent yesterday.
Client Rights-Information: Facility provides telephone landline for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained within the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files and no issue were observed.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPA reviewed 4 client’s medications during and C4 had medications that are no longer administered and had no DC order.
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Disaster Plan needs updating. Facility does not maintain documentation of the required emergency drills. With the last drill was 02/25/25.
Emergency Intervention: Clients do not require the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.
Exit interview was held, a copy of the report provided to Staff Jeanybave Silvosa and Administer Olivia Tomines
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
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Document Has Been Signed on 03/11/2025 04:39 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/11/2025 at 03:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JAY & JESS GROUP HOME LLC
FACILITY NUMBER: 198603713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The hot water measured 155.8 to 158.9 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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Administrator will adjust water and keep a log for one week and send to LPA as proof.
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above. There was medications for C4 that were never taken and in the client's medication box which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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Administrator will obtain DC order for C4 medication and dispose of medication properly by taking it to pharmacy.
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
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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