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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001397
Report Date: 10/06/2021
Date Signed: 10/06/2021 01:33:16 PM

Document Has Been Signed on 10/06/2021 01:33 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JONATHAN'S HOMEFACILITY NUMBER:
306001397
ADMINISTRATOR:PRISCILLA S. BUSTAMANTEFACILITY TYPE:
735
ADDRESS:1519 SHELTON STTELEPHONE:
(714) 754-7184
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY: 6CENSUS: 2DATE:
10/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:House Manager, Levi MiraTIME COMPLETED:
01:45 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre was out conducting a 10 day visit to facility and during visit LPA toured facility and observed property damage at facility allegedly made by client during aggressive behavior outbursts. House Manager stated that observed holes in walls, unhinged door and broken ceiling fan were made by Client 1 (C1). House Manager stated that on September 27,2021 C1 had bad outburst and used a portable speaker to punch holes into the walls of facility. That same day C1 had a confrontation with next door neighbor threatening to harm them. House Manager apologized to neighbor for behavior of C1 and contacted Orange County Crisis Assessment Team to come out and check on C1. Crisis Team contacted Santa Ana Police Department to meet at facility as well. By the time Crisis Team and PD arrived C1 was at coroner of Shelton Street and Edinger. C1 was taken to OC global medical center on a 5150. No other clients or staff were harmed. During today's visit clients were observed to be in good spirits as evidenced by cooperation to talk with LPA during visit and eagerly showing LPA around facility.

LPA informed House Manager that damage to walls, door, and ceiling fan need to be repaired and are not safe living conditions. House Manager stated that Licensee is aware of damages and is getting an estimate to work on repairs. Facility to work on repairing damages and have fixed by November 3, 2021.

An exit interview was conducted with House Manager Levi Mira. A copy of LIC 811 and a copy of report was left at facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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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