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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003735
Report Date: 02/02/2023
Date Signed: 02/02/2023 01:50:11 PM

Document Has Been Signed on 02/02/2023 01:50 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: 4DATE:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Vilma Tumale
Rosalina Amante
Louise Igisaiar		TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was granted entry into the facility. LPA Gutierrez discussed the purpose of the inspection with Staff Vilma Tumale and Rosalina Amante. Administrator (AD) Louise Igisaiar arrived at 12:54 p.m. During the inspection LPA Gutierrez and Staff Amante conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a single-story house with six client bedrooms, and two bathrooms. During the inspection LPA observed two staff and three clients in care. Per staff, an additional client is away at day program. Clients were observed resting in their bedroom and in the living room area. A 2-day supply of perishable and a 7-day supply of non-perishable foods was observed during today’s visit. Upon record review LPA noted emergency care requirements were met. LPA observed the facility has a 30-day supply of PPE on hand. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices with Staff Tumale regarding resident screening, staff screening, visitation, COVID-19 testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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