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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003734
Report Date: 03/14/2024
Date Signed: 03/14/2024 10:13:11 AM

Document Has Been Signed on 03/14/2024 10:13 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:JAIRE HOME IFACILITY NUMBER:
306003734
ADMINISTRATOR:LOUISE IGISAIARFACILITY TYPE:
735
ADDRESS:800 LA REINA STREET, N.TELEPHONE:
(714) 995-5575
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 6DATE:
03/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Eppieabien Mendoza- Care StaffTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho continued the visit after continuing the investigation into Complaint Control Number: 22-AS-20231221160503. LPA stated the purpose of the visit to Care Staff (CS) Eppieabien Mendoza. LPA observed Staff #1 (S1) was not associated per the Guardian Employee Roster dated March 14, 2024 at 8:28am as required per the Criminal Record Clearance of the Title 22 Regulations. S1 was employed effective January 29, 2024.

A deficiency is being cited as per the Title 22, Division 6, Chapter 1 of the California Code of Regulations. See the attached LIC809-D. An immediate civil penalty is being assessed. See the attached LIC421BG.

Administrator Louise Igisaiar consented by telephone at 9:15am to sign the report on her behalf.
An exit interview was conducted with Care Staff Eppieabien Mendoza, and a copy of this report including the LIC809D, LIC421BG, LIC811, and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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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Document Has Been Signed on 03/14/2024 10:13 AM - It Cannot Be Edited


Created By: Jessica Cho On 03/14/2024 at 09:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JAIRE HOME I
FACILITY NUMBER: 306003734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2024
Section Cited
CCR
80019(e)(3)

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80019 Criminial Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) "Request a transfer of a criminal record clearance..."
This requirement was not met as evidenced by:
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Admin stated that S1 will be associated by POC due date and will submit an Acknowledgement of Understanding of the said regulation to LPA via email by POC due date.
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Based on observation, interviews, and record review, S1 was not associated at the time of the visit which poses an immediate Health, Safety, and Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024


LIC809 (FAS) - (06/04)
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