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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003735
Report Date: 03/29/2024
Date Signed: 03/29/2024 12:47:49 PM

Document Has Been Signed on 03/29/2024 12:47 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
ORANGE COUNTY RO, 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: 5DATE:
03/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ariel Resureccion- LicenseeTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose to conduct the Required 1 Year Annual Inspection. LPA was greeted by Care Staff (CS) Vilma Tumale and was granted entry. Licensee Ariel Resureccion arrived on premise approximately 10:00am and was advised of the visit.

This is a single story, Level 4a facility comprised of six client bedrooms with two client bathrooms, living/dining area, kitchen, attached laundry room and a two-car garage, and one shed in the backyard. LPA toured inside the facility. LPA observed the client bedrooms had all the required elements with ample lighting. Showers, faucets, and toilets were clean and sanitary. The hot water temperature measured at 115.8 and 116.0 degrees Fahrenheit in the two bathrooms. There were sufficient and clean supply of linens. LPA observed ample two-day supply of perishables and seven-day supply of non-perishables. LPA observed emergency food and water supplies. The carbon monoxide and smoke detectors were tested and operational. The fire extinguisher was mounted, charged, and serviced on March 19, 2024. Medications, toxins, and sharps were locked and inaccessible to the clients. LPA toured the outside grounds. Both exit gates were self-closing and self-latching.There was sufficient shading and seating for the clients. The following items were posted and reviewed: Emergency Disaster Plan (LIC610D), food menu, activities, client's rights, and the Complaint Poster (PUB475). LPA reviewed five out of five client files, three out of five clients' medications as one client was admitted to the hospital and the other was staying with their family, and four out of five P&I funds as one client's funds were managed by the family. Based on the review of the P&I ledgers, it appeared that facility was not documenting the ledgers accurately. LPA also reviewed one out of the one staff file and attempted interviews with two clients and one staff who was present at the time of interview.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2024
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 03/29/2024 12:47 PM - It Cannot Be Edited


Created By: Jessica Cho On 03/29/2024 at 12:07 PM
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 II
FACILITY NUMBER: 306003735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)

80069 Client Medical Assessment (c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, and record review, the licensee did not comply with the section cited above in one out of five clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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Licensee stated that the Physician's Report with the TB test results will be submitted to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 306003735
VISIT DATE: 03/29/2024
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Licensee was advised on the following: to ensure no clients are admitted to the facility without proper medical assessments and TB testing and to accurately document the P&I ledgers.

Based on today's observations, a deficiency is being cited as per the Title 22 Division 6 Chapter 1 of the California Code of Regulations. Technical Advisories are being issued.

An exit interview was conducted with Licensee Ariel Resureccion, and a copy of this report including the LIC9099C, LIC9099D, Technical Advisories, 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: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC809 (FAS) - (06/04)
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