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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003734
Report Date: 03/15/2022
Date Signed: 03/15/2022 03:23:07 PM

Document Has Been Signed on 03/15/2022 03:23 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JAIRE HOME IFACILITY NUMBER:
306003734
ADMINISTRATOR:ANA BIEN DEVERAFACILITY TYPE:
735
ADDRESS:800 LA REINA STREET, N.TELEPHONE:
(714) 995-5575
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 4DATE:
03/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Louise IgisalarTIME COMPLETED:
03:37 PM
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Licensing Program Analysts (LPAs) Joseph Alejandre and Andrea Mendivil made an unannounced visit to conduct the required annual inspection (mitigation). LPAs were greeted and granted entry by staff. LPAs met with Administrator Louise Igisalar. LPA's explained the reason for the visit. Administrator Louise Igisalar's Administrator's certificate expires on 12/05/2023. Facility is single story home with 6 client bedrooms and 1 staff bedroom with 3 bathrooms, living room, dinning room, kitchen and an attached two car garage. At 1:10pm LPA's and Administrator toured facility. LPAs observed all client rooms had the required furnishings and clean bed linens. All client rooms had enough space to accommodate the client's and all of their belongings and each client has their own room. LPAs observed all 3 bathrooms were operational and clean, all grab bars were secure. Hot water measured between 107.2 degrees Fahrenheit to 113.5 degrees Fahrenheit. Smoke detectors/carbon monoxide tested and operational. Fire extinguisher was inspected on 04/19/2021 and is fully charged. LPAs observed that living room has TV, puzzles and games for clients. LPAs observed the fire place is screened. LPAs observed medication is kept in a medical closet that is locked. LPAs observed knives are kept in the garage. At 1:45pm toured the backyard. LPAs observed a swimming pool. The swimming pool is fenced and gate is locked. The pool is visible through the 5 foot rod iron fence. LPAs observed a metal storage shed that contained cleaning supplies and paper goods. The storage shed is kept locked and inaccessible to clients. Both exit gates leading out of backyard are operational. No obstacles or hazards observed in the backyard. At 2:05pm LPAs toured kitchen. LPAs observed that the kitchen is cleaned and organized. LPAs observed that the stove is operational. No hazardous or dangerous items kept in the kitchen. LPAs observed a 2 day perishable and 7 day non perishable kept in the kitchen. At 2:35pm reviewed client files. LPA's inspected first aid kit and the first aid kit had all required elements. Facility has a mitigation plan pending review. LPAs did not observe any deficiencies during the visit. No deficiencies are being cited as a result of this visit. At 3:20pm LPA Mendivil read report to administrator. An exit interview was conducted with administrator and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
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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