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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002719
Report Date: 06/22/2022
Date Signed: 06/22/2022 04:10:02 PM

Document Has Been Signed on 06/22/2022 04:10 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:J & S HOMEFACILITY NUMBER:
306002719
ADMINISTRATOR:JOSE D. VILLAREALFACILITY TYPE:
735
ADDRESS:11672 POES STREETTELEPHONE:
(714) 636-5219
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 5CENSUS: 5DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Jose VillarealTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted by Administrator (AD) Jose Villareal and granted entry into the facility. LPA Gutierrez discussed the purpose of the inspection. During the inspection LPA Gutierrez and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a single-story house with six bedrooms, two bathrooms, and an office; one bedroom is occupied by staff. Residents were observed resting in their respective rooms and returning from day program. A 2-day supply of perishable and a 7-day supply of non-perishable food was observed during today’s visit. Upon record review LPA noted emergency care requirements were met. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices regarding resident screening; a Technical Advisory was given on this date, staff screening, visitation, COVID-19 testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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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