<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003736
Report Date: 03/08/2024
Date Signed: 03/08/2024 12:52:13 PM

Document Has Been Signed on 03/08/2024 12:52 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JAIRE HOME IIIFACILITY NUMBER:
306003736
ADMINISTRATOR:FLERIDA RESURRECCIONFACILITY TYPE:
735
ADDRESS:10602 BORWICK STREETTELEPHONE:
(562) 804-3886
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Flerida Resurreccion - AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPAs) Tena Herrera and Daniel Konishi conducted the required unannounced annual inspection. LPAs met with Administrator Flerida Resurreccion and explained the reason for the visit. The facility is licensed to serve 3 Ambulatory and 1 Non-Ambulatory adults ages 18-59. Facility currently has 4 Ambulatory clients serviced by Harbor Regional Center.

The facility is a single-story home located in a residential area in Bellflower, Ca. A tour of the facility includes: living room, dining area, kitchen, 4 client bedrooms, 1 staff bedroom, 2 bathrooms, attached garage, front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathroom and was outside the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet in the garage and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 3/2/24.
(continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 03/08/2024 12:52 PM - It Cannot Be Edited


Created By: Tena Herrera On 03/08/2024 at 12:11 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JAIRE HOME III
FACILITY NUMBER: 306003736

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as 2 out of 4 (Staff 1&2) client files reviewed did not have valid first-aid training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
1
2
3
4
Administrator/Licensee to review all staff files and all staff that do not have a valid First-Aid certificate must be provided training and a copy of valid certificates must be emailed to LPA by POC due date, including certificates for Staff 1&2.
Type B
Section Cited
CCR
80072(a)(7)

80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (7) Not to be locked in any room, building, or facility premises by day or night.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as during tour LPAs observed side gate to be locked with a master lock which requires key to open, when LPA asked why this was locked administrator stated that there is a client who wanders/tries to exit facility so they use this as a preventative, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
1
2
3
4
**Administrator unlocked side gate during visit and removed lock from gate**
Administrator to review regulation and sign statement stating that they are familiar with regulation and will not lock gate unless facility updates fire clearance and sends copy of updated fire clearance to LPA for review. Review of regulation and signed statement to be emailed to LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JAIRE HOME III
FACILITY NUMBER: 306003736
VISIT DATE: 03/08/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, CPR/AED/CPI and sufficient on-going training. LPAs observed 2 staff files missing their First-Aid Certificates (citation will be documented on the 809D). Administrator Flerida Resurreccion maintains a valid certificate that expires on 5/13/2024.
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility. LPAs observed exterior exit to be locked with a master lock that requires key to open (citation will be documented on 809-D).
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPAs reviewed 4 client’s medications during todays visit with no issues.
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques, however, some staff maintain a CPI Certificate in the case of use.

One staff interview was conducted and zero client interviews as clients were away at day program.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during todays visit will be cited in the 809-D.

Exit interview was held and a copy of the report was given to Administrator Flerida Resurreccion.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3