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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003735
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:08:06 PM

Document Has Been Signed on 03/10/2022 03:08 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 IIFACILITY NUMBER:
306003735
ADMINISTRATOR:ANA BIEN DEVERAFACILITY TYPE:
735
ADDRESS:1242 ALAMO STREETTELEPHONE:
(714) 635-3788
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 3DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mylene Del Rosario, Louise Igisaiar TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA explained the reason for the visit. LPA met with Administrator Louise Igisaiar. LPA and Administrator toured the facility. Facility is a single story home with 6 bedrooms and 2 bathrooms, kitchen, living room with a screened fireplace, dining room and a 2 car garage. All smoke detectors/carbon monoxide detectors tested operational. Hot water in both bathrooms measured 106.0 degrees Fahrenheit. LPA observed all client bedrooms had the required furnishings. Each client had their own room. LPA observed a 2 day perishable food supply and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the cleaning supplies and sharp objects are kept locked in the garage. The garage is used for storage. LPA observed the kitchen is clean and organized. The stove lights unassisted. The fire extinguisher in the kitchen is fully charged. LPA observed the medication is kept locked in a metal storage closet. LPA inspected the First Aid Kit. The First Aid Kit has all the required elements. LPA and Administrator toured the backyard. No bodies of water observed. Both exit gates are operational. LPA observed a storage shed. The storage shed is used to store tools and supplies. The storage shed is kept locked and inaccessible to clients. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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