<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003493
Report Date: 03/30/2023
Date Signed: 04/04/2023 05:17:58 PM

Document Has Been Signed on 04/04/2023 05:17 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:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Administrator Daryl Abarquez TIME COMPLETED:
11:40 AM
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) Jose Villalobos made and unannounced Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. On today’s visit LPA met with Staff Adolfo Morado and the purpose of the visit was discussed. Licensee Dominick Abarquez and Administrator Daryl Abarquez arrived shortly after.

LPA conducted a tour of the facility along side staff Adolfo. Facility is a one story family home with four (4) client bedrooms, one (1) staff room, Two (2) bathrooms, living room, kitchen, dining area, a den, an attached garage for laundry and storage, and a backyard with shaded area for clients. There are currently four (4) clients living in the facility.

Physical Plant: Outdoor and indoor passageways are free of obstruction. Bathrooms were clean and operational with non-skid mats, water temperature in compliance. Smoke/carbon monoxide detectors were tested and operational. The last fire drill was conducted on 3/4/23. Fire extinguisher observed. Required postings observed. Sufficient supply of extra linen, towels and personal hygiene supplies observed. Central Air and Heating with temperature comfortable. Washer/Dryer appliances observed and operational. Front and back yard is in good condition, shaded area is provided. Required food supply was observed. Toxins and sharps locked and inaccessible to clients. BEDROOMS: Bedrooms #1-#4 had required furnishing. All client beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket.
MEDICATION: Medications are stored, locked and inaccessible to clients. LPA reviewed three (3) client medications. One (1) client was on vacation with family and took their medication. RECORD REVIEW: Administrator Certificate for Daryl Abarquez expires 10/9/24. Four (4) Staff Files reviewed. Four (4) client files reviewed

Care Tool was completed and based on Title 22 Regulations, no Deficiencies will be documented.
An exit interview was conducted and a copy of today's report was provided and discussed.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1