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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300605586
Report Date: 07/15/2022
Date Signed: 07/15/2022 11:44:10 AM

Document Has Been Signed on 07/15/2022 11:44 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PEOPLE IN PROGRESS-JEFFERSONFACILITY NUMBER:
300605586
ADMINISTRATOR:DANE SYNDERFACILITY TYPE:
735
ADDRESS:5372 JEFFERSON RD.TELEPHONE:
(714) 996-5358
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 5DATE:
07/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:LeShawn Malone - Direct Support Professional
Tim Gue - Assistant Administrator		TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to People in Progress - Jefferson. The purpose of today's visit was to conduct a Required 1 Year inspection focusing primarily on Infection Control. LPA Velazquez was allowed entry into the facility and met with Direct Support Professional (DSP) LeShawn Malone. Assistant Administrator (AA) Tim Gue arrived later to assist with the visit. The facility is licensed for 6 ambulatory clients. There are currently 5 clients living in the facility. The last emergency disaster drill was conducted on June 15, 2022. LPA Velazquez informed AA Gue of the facility's overdue annual fees and provided a copy of the Facility Transaction History including a PIN so the fees can be paid online. AA Gue will submit proof of payment to LPA Velazquez by 7/16/2022.


At 10:05 AM LPA Velazquez conducted a tour of the physical plant along with DSP Malone. The 1 story home consists of 3 client bedrooms with 2 bathrooms. There is 1 staff bedroom and 1 staff bathroom. The facility also has a living room, family room, dining area, and kitchen. The 5 clients in the facility appeared well-groomed and well cared-for. The client bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, showers were free of mold/mildew and a non-skid surface or mat was in place. Client bath towels and personal hygiene supplies were adequately stocked. LPA Velazquez tested the hot water temperature in the client bathrooms and the temperature measured at 136.0 degrees Fahrenheit in the first bathroom and at 132.4 degrees Fahrenheit in the second bathroom which DSP Malone verified.

LPA Velazquez inspected the kitchen along with DSP Malone. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PEOPLE IN PROGRESS-JEFFERSON
FACILITY NUMBER: 300605586
VISIT DATE: 07/15/2022
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The fire extinguishers were fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Medications, toxins and sharps were locked and inaccessible to clients.

LPA Velazquez along with DSP Malone toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for clients but some of the seat cushions were torn which DSP Malone verified. Walkways around the home were clear of hazards. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit. Client medications and Medication Administration Records were not reviewed during this inspection.



Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 1. An exit interview was conducted with Assistant Administrator Tim Gue and a copy of this report along with the appeal rights and a copy of the LIC 9098 were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/15/2022 11:44 AM - It Cannot Be Edited


Created By: Patricia Velazquez On 07/15/2022 at 10:55 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PEOPLE IN PROGRESS-JEFFERSON
FACILITY NUMBER: 300605586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088(e)(1) Furniture, Fixtures, Equipment, and Supplies. (e) Faucets used for 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 C) and not more than 120 degrees F (48.8 C)
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 2 bathrooms where the hot water temperature measured at 136.0 degrees F in the first client bathroom and at 132.4 degrees F which DSP Malone verified. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2022
Plan of Correction
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Licensee to ensure the hot water temperature is maintained pursuant to regulation at all times and submit written proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022


LIC809 (FAS) - (06/04)
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