306002719-9-22-2023-22-AS-DLMN-CVWSSD-20230922140747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002719
Report Date: 09/22/2023
Date Signed: 09/22/2023 02:08:57 PM

Document Has Been Signed on 09/22/2023 02:08 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	J & S HOME		FACILITY NUMBER:	306002719
ADMINISTRATOR:	JOSE D. VILLAREAL		FACILITY TYPE:	735
ADDRESS:	11672 POES STREET		TELEPHONE:	(714) 636-5219
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY: 5		CENSUS: 4	DATE:	09/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Jean Camacho - Administrator		TIME COMPLETED:	02:30 PM

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) Dwayne Mason Jr. arrived at J & S Home to conduct an unannounced Required 1 Year Inspection. At 11:45am, LPA was greeted by Administrator (AD) Jean Camacho. Structure: The facility is a one-story home with 5 resident bedrooms, 2 bathrooms, living room, kitchen, staff bedroom, office, an attached one car garage and a backyard. The fireplace is screened. Client Bedrooms: All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Toxins: LPA observed toxic chemicals to be accessible in the laundry room, garage, bathroom and backyard shed. AD mentioned that the staff was in the middle of cleaning. LPA stated that they understand staff was presently cleaning. LPA also stated that laundry detergent was left out, but no laundry was being done. LPA also stated that the key was left inside the lock to the shed, but yard work was not being done. Due to the immediate nature of the risks, LPA stated the facility would be issued a deficiency. Medications: Stored in a locked cabinet in the kitchen. LPA observed medication to be organized, separated and administered as prescribed. Resident, Staff Files & Record Review: Records are kept in the Office. LPA reviewed 4 out of 4 client files and the Personnel files. Upon record review and discussion with AD, LPA noted that the only disaster drill conducted in 2023 was conducted on June 17, 2023. LPA informed the AD of the required frequency of disaster drills. A deficiency is being given on this day. Upon review of the Personnel Report and discussion with AD, LPA noted that AD Jean Camacho is not associated with the facility. AD showed proof of submitting a request to associate herself, however, AD had not followed up on the status of the request until the LPA's visit. A deficiency is being given on this day.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: J & S HOME	FACILITY NUMBER: 306002719
	VISIT DATE: 09/22/2023

NARRATIVE

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Fire Extinguisher: The fire extinguisher is fully charged.

Activity Materials: The facility has books, toys, musical equipment, air hockey, board games, and exercise equipment for client use.

Staff: One bedroom will be occupied by staff. There is also Office space utilized by staff

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 109.9 degrees Fahrenheit in the bathroom next to BR 3. Hot water measured at 108.9 degrees Fahrenheit in the bathroom next to the laundry area.

Linens & Hygiene Supplies: A supply of extra linen was stored in the hallway storage. Hygiene supplies are stored in the garage.

Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review

Food Service: There is a 2-day supply of perishable food and 7-day supply of non-perishable food on hand.

Smoke/CO2 Detectors: Smoke detectors and carbon monoxide detectors tested operational.

Appliances: Gas 4 burner stove, oven, 3 refrigerators, dishwasher, microwave, washer/dryer are operational.

Based on the observations made during today's visit, three deficiencies are being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted with Administrator Jean Camacho and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/22/2023 02:08 PM - It Cannot Be Edited

Created By: Dwayne L Mason On 09/22/2023 at 01:31 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: J & S HOME	FACILITY NUMBER: 306002719
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in four instances. LPA observed toxins to be accessible in laundry area, bathroom near laundry area, garage and backyard shed. This poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/25/2023
	Plan of Correction
1 2 3 4	The licensee made the following corrections during the visit: 1. Licensee locked the bathroom cabinet. 2. Licensee moved laundry toxins into a locked cabinet. 3. Licensee locked the garage door. 4. Licensee removed the key from the lock on the shed and placed it in a location only the staff are aware of.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Dwayne L Mason

LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/22/2023 02:08 PM - It Cannot Be Edited

Created By: Dwayne L Mason On 09/22/2023 at 01:38 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: J & S HOME	FACILITY NUMBER: 306002719
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80077.3(a)(3)(C)

(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and discussion with the licensee, the licensee did not comply with the section cited above as evidenced by the facility's disaster drill log. LPA noted that the only disaster drill conducted this year occurred on June 17, 2023 which poses a potential safety risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	The Licensee will conduct their next disaster drill by 09/29/2023 the assigned POC due date. The facility will maintain record of their disaster drills by documenting the drills quarterly and keeping the forms in their folder. By the assigned POC due date the Administrator will email a copy of the completed disaster drill form following the facility's next disaster drill.

Type B

Section Cited

CCR

80019(e)(3)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as administrator is not associated with facility.This poses a potential safety risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Licensee to ensure staff have proper transfer of their criminal record clearance and submit proof via email to LPA by POC due date of 09/29/2023.

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Dwayne L Mason

LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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