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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002719
Report Date: 08/02/2024
Date Signed: 08/02/2024 11:00:09 AM

Document Has Been Signed on 08/02/2024 11:00 AM - 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:J & S HOMEFACILITY NUMBER:
306002719
ADMINISTRATOR/
DIRECTOR:		JOSE D. VILLAREALFACILITY TYPE:
735
ADDRESS:11672 POES STREETTELEPHONE:
(714) 636-5219
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 5CENSUS: 4DATE:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Jean Camacho, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #2 (S2). During today’s visit, LPA met with Jean Camacho, Administrator (AD) and Joey Villareal, Licensee (LE).

The facility is a level 4e single story building with an approved fire clearance of five non-ambulatory clients. The facility currently has a census of four clients in care. At 8:00 AM LPA observed three clients loading for transport to Day Program.

At 8:05 AM LPA spoke with Client 1 (C1) and conducted file reviews while waiting for AD to arrive. LPA reviewed three of three staff training and fingerprint records and conducted a complete review of client records. Client P&I records were reviewed and were accurate. LPA interviewed one alert client regarding the quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on June 7, 2025. Facility will provide Admissions Agreements to comply with Title 22 Regulations. A technical violation was given.

During today's visit at 9:30 AM, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperatures in two of two client bathrooms, and testing auditory devices on all exits. The hot water temperature measured 105 degrees Fahrenheit in both restrooms and all smoke detectors were operational. The fire extinguisher is charged and was serviced on February 27, 2024. The facility’s last fire drill was conducted on February 28, 2024. All client bedrooms had the required furnishings and there was covered seating in the outdoor patio. All sharps and toxins were secured in locked cabinets.

(Continued on LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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: J & S HOME
FACILITY NUMBER: 306002719
VISIT DATE: 08/02/2024
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(Continued from LIC 809)

LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Jean Camacho, AD and Joey Villareal, LE and a copy of the report and files reviewed (LIC 858 & LIC 859), LIC 9102-TV and Entrance checklist were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
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