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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003734
Report Date: 10/03/2022
Date Signed: 10/03/2022 01:45:36 PM

Document Has Been Signed on 10/03/2022 01:45 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:LOUISE IGISAIARFACILITY TYPE:
735
ADDRESS:800 LA REINA STREET, N.TELEPHONE:
(714) 995-5575
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 6DATE:
10/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Analouise IgisaiarTIME COMPLETED:
02:00 PM
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On 10/03/2022 at 10:03am, Licensing Program Analyst (LPA) conducted an unannounced case management visit. LPA was greeted and granted entry by Facility Staff (FS) Eppieabien Mendoza and completed the Coronavirus 2019 (COVID-19) screening procedure. FS Eppieabien Mendoza notified Administrator (Admin) Analouise Igisaiar via a telephone a call and arrived at the facility around 10:10am. LPA met with Admin and stated the purpose of the visit. LPA requested and reviewed records for Client #1 (C1) to Client # (C6) and obtained copies of the following pertinent records per client: IPP and Admission Agreement. Time sheets for Staff 1 (S1) to Staff 9 (S9) were requested indicating the days and hours worked during the last 3 months. In addition, the Purchase of Service (POS) for C3 and C5 were requested. Admin requested the information to the facility's HR representative, but was unable to provide the information during the visit. Due to time constraints, Admin agreed to provide the aforementioned staff documents and client POS to LPA by COB Thursday, October 6, 2022.


An exit interview was conducted, and a copy of this report along with the 811s were provided to Administrator Analouise Igisaiar.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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