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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001397
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:49:27 PM

Document Has Been Signed on 08/28/2024 04:49 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JONATHAN'S HOMEFACILITY NUMBER:
306001397
ADMINISTRATOR/
DIRECTOR:		PRISCILLA S. BUSTAMANTEFACILITY TYPE:
735
ADDRESS:1519 SHELTON STTELEPHONE:
(714) 754-7184
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY: 6CENSUS: 1DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Agnes MontoyaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On August 28, 2024 at 12:15pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by House Manager (HM) Agnes Montoya. LPA Kim spoke with Assistant Administrator (AA) Ernie Bustamante and explained the purpose of the visit. AA Bustamante could not be present during the visit.

The facility is licensed to operate for six (6) nonambulatory clients. The facility is a single story structure located in a residential neighborhood. It consists of the following: Three (3) client bedrooms, one (1) Staff Bedroom, two (2) bathrooms, living area, dining area, den, kitchen, office area, and detached garage.

LPA Kim toured inside and outside of the physical plant with HM Montoya. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Client’s rooms were inspected: Client Room 1, Client Room 2, Client Room 3, and Staff Room. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 116.6 degrees F. A comfortable temperature of 77 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the office area. The facility has (1) fire extinguisher that was charged, mounted in the garage, and serviced on February 22, 2024.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JONATHAN'S HOME
FACILITY NUMBER: 306001397
VISIT DATE: 08/28/2024
NARRATIVE
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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and clients. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (657-500-8048) remains available. First Aid kit had all the necessary elements.

LPA Kim conducted an audit of client file (C1), staff files (S1-S3), and medication and medication administration review. LPA Kim conducted one (1) staff interviews..

Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 1 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to House Manager Agnes Montoya.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/28/2024 04:49 PM - It Cannot Be Edited


Created By: Edward Kim On 08/28/2024 at 03:47 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JONATHAN'S HOME
FACILITY NUMBER: 306001397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed and interviewed staff that there are no records of completed quarterly emergency safety drills. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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Licensee states they will perform an emergency safety drill monthly and will complete an emergency drill and provide proof to CCLD via email to edward.kim@dss.ca.gov by September 9, 2024.
Type B
Section Cited
CCR
80066(a)
80066 Personal Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:


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. LPA observed S2 was missing LIC 501 and training hours, and S3 was missing LIC503 and training hours. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
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Licensee states they will provide completed LIC501 and training hours for S2, and LIC503 and training hours for S3 to CCLD via email to edward.kim@dss.ca.gov by POC due date September 11, 2024
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/28/2024 04:49 PM - It Cannot Be Edited


Created By: Edward Kim On 08/28/2024 at 04:11 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JONATHAN'S HOME
FACILITY NUMBER: 306001397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(A)
80070 Client records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed C1 was missing a completed Physican's Report, Consent form, and Personal Rights form. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
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Licensee states they will provide a completed Phsycian's report, Consent form, and Personal Rights form to CCLD via email to edward.kim@dss.ca.gov by POC due date September 11, 2024.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


LIC809 (FAS) - (06/04)
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