306003493-1-13-2024-28-AS-THEA-CZFR8V-20240113114833

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003493
Report Date: 01/13/2024
Date Signed: 01/13/2024 11:48:38 AM

Document Has Been Signed on 01/13/2024 11:48 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	JKC HOME		FACILITY NUMBER:	306003493
ADMINISTRATOR:	DARYL ABARQUEZ		FACILITY TYPE:	735
ADDRESS:	15561 ASHGROVE DRIVE		TELEPHONE:	(714) 266-0078
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY: 4		CENSUS: 4	DATE:	01/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:16 AM
MET WITH:	Daryl Abarquez - Administrator		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Manoucheher Sodavy (House Manager) and Dominic Abarquez (Licensee) who later assisted with the visit, the reason for the visit was explained. The facility is licensed to serve 4 ambulatory clients ages 18-59. Facility currently has 4 ambulatory clients serviced by Eastern Los Angeles Regional Center.

The facility is a single-story home located in a residential area in Whittier, Ca. A tour of the facility includes: living room, dining room, kitchen, den, linen closet, 2 bathrooms, 5 bedrooms (1 is a staff room), detached garage with laundry, front yard, back yard and a locked storage shed.

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.

Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 12/7/23.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
(Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JKC HOME	FACILITY NUMBER: 306003493
	VISIT DATE: 01/13/2024

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Personnel Records-Training: Staff files are maintained in a locked cabinet. LPA reviewed 4 staff files during today’s visit with no issues observed. All files reviewed contained the following: criminal record clearance, current First Aid/CPR/AED and sufficient on-going training. Administrator Daryl Abarquez certificate expires on 10/09/2024.
Client Rights-Information: The facility does not have any clients that require postural supports. Facility provides telephone landline for the clients. Client rights posters and reporting posters are displayed throughout facility.
Client Records-Incident Reports: Client files are maintained in the locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 3 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a cabinet and are in their original containers. LPA reviewed 2 clients medications and there were no issues observed. (1 client is currently away with family and 1 client is currently at a skilled nursing facility)
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills, with the last drill conducted on 12/7/23.
Emergency Intervention: Clients at this facility have not needed the use of restraints or the use de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview was held and a copy of the report was provided to Administrator Daryl Abarquez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

LIC809 (FAS) - (06/04)

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