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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002719
Report Date: 09/22/2023
Date Signed: 09/22/2023 02:14:30 PM

Document Has Been Signed on 09/22/2023 02:14 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 HOMEFACILITY NUMBER:
306002719
ADMINISTRATOR:JOSE D. VILLAREALFACILITY TYPE:
735
ADDRESS:11672 POES STREETTELEPHONE:
(714) 636-5219
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 5CENSUS: 4DATE:
09/22/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced POC visit to J & S Home on 09/22/2023. LPA met with Administrator (AD) Jean Camacho to verify corrections made to make toxins inaccessible to clients in care. The following corrections were verified:

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.

Based on LPA observations, the licensee fulfilled the plan of corrections by the POC due date of 9/25/2023
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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