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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003493
Report Date: 04/28/2022
Date Signed: 04/28/2022 03:48:29 PM

Document Has Been Signed on 04/28/2022 03:48 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JKC HOMEFACILITY NUMBER:
306003493
ADMINISTRATOR:DARYL ABARQUEZFACILITY TYPE:
735
ADDRESS:15561 ASHGROVE DRIVETELEPHONE:
(714) 266-0078
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 4DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Administrator Daryl AbarquezTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Jose Villalobos made an unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Licensee Domingo Abarquez and Administrator Daryl Abarquez arrived shortly after. The purpose of the visit was discussed.

As a part of the inspection, LPA used the inspection tool, reviewed (4) client records, (3) staff files, and (4) client medications. Currently the facility has (4) clients of which (2) are ambulatory and (2) are non-ambulatory. The facility is vendorized through Eastern Los Angeles Regional Center. Facility is a one story family home with four (4) bedrooms. Each bed room is for one (1) client. There are (2) bathrooms for client use. There is also a living room, a den, a kitchen, central air and heating, a dining area, staff room, a laundry room, a shaded area located in the backyard. A detached car garage inaccessible to clients. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. Bedrooms #1-#4 are equipped with a (1) beds each, a dresser, lamp, chair, overhead lightning for each client. Bathroom #1-#2 has a working toilet, wash basin, and shower. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies were observed. Fire alarms are interconnected and operational. Required postings observed. Water temperature within required tittle 22 regulations.

Infection control domain completed and there were no deficiencies. An exit interview was conducted and a copy of this report was provided to Administrator Daryl Abarquez
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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