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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603757
Report Date: 08/05/2024
Date Signed: 08/05/2024 11:33:34 AM

Document Has Been Signed on 08/05/2024 11:33 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:JENESIS HOMES 3FACILITY NUMBER:
198603757
ADMINISTRATOR/
DIRECTOR:		LOSOYA, MARTHAFACILITY TYPE:
735
ADDRESS:15137 CERECITA DRIVETELEPHONE:
(562) 325-8809
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 4CENSUS: 0DATE:
08/05/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Joann Mocling and Martha Losoya TIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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) Angelica Rea conducted an announced visit with Licensee Joann Mocling and Administrator, Martha Losoya. The purpose of the visit was to conduct the Pre-Licensing visit.
An application was submitted to CCLD on 2/22/2024 for an Initial License of a Adult Residential Facility for. The requested capacity of 4 clients, (4) ambulatory, (0) non-ambulatory and (0) may be bedridden.

Structure/Physical Plant:
The facility is a single story home located in a residential area and contains the following: a living room, dining room, office area, laundry area, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for medications, locked drawer for sharps, (4) resident rooms, (2) bathrooms; each bathroom with shower, toilet and washbasin. A backyard with shaded area and seating for resident use. An attached garage inaccessible to clients, will be used for storage. The residence is equipped with central air and heating.
Accommodations: Adequate accommodations observed throughout facility. Lighting: Sufficient Lighting throughout, including night lights, and flash lights for emergencies. Hallway and Doorways: Free and clean of obstruction and debris. Client Rooms: All bedrooms are equipped with required overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawers, and closet space. Bathrooms: Bathroom #1 and #2 all have a working toilet, wash basins, showers, grab bars and nonskid mats. Linens & Hygiene Supplies: Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads. Mattress pads were observed. Emergency Phone Numbers, Emergency Exit Plan & Menu: Facility has a working phone landline. There is (3) cordless phones for residents use. Fire Extinguisher is fully charged and up to date. Emergency Exit plan posted. Food Menu(s) observed. Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates observed. Knives, cutlery and other sharps inaccessible to residents will be kept in a locked cabinet. Laundry area: Located next to the kitchen, with washer and dryer, and locked cabinets for laundry detergent, and toxins.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024
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: JENESIS HOMES 3
FACILITY NUMBER: 198603757
VISIT DATE: 08/05/2024
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
Smoke Detectors, Carbon Monoxide Detector, & Fire Extinguishers: Smoke detectors are battery operated & working. There is one carbon monoxide detector, and it was tested and working. Appliances: Stove burners and oven operational. Microwave, washer, and dryer are operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured between 105 -120 degrees at sinks tested. Medications, First-Aid Kit & Book: Medications area observed in the office area. First aid kit inspected which contains: thermometer, tweezers, scissors, antiseptic, bandages, gauze, which is available for staff use. First aid manual observed Client & Staff Files: Facility has a locked cabinet for resident and staff files. Client and Staff files will be kept in the dining area. Reading Material, Games, Equipment & Materials, Postings: The facility has activity supplies and an activities calendar posted. Required wall postings observed. Bodies of Water: None. Pets: None. Fire clearance: Fire clearance was approved on 5/21/24.

Physical Plant is cleared at the time of visit.

Component III:
Component III was conducted at the time of this visit.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2