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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003736
Report Date: 03/19/2024
Date Signed: 03/19/2024 09:48:48 AM

Document Has Been Signed on 03/19/2024 09:48 AM - 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:
03/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Rafael Chiu - CaregiverTIME COMPLETED:
10:00 AM
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 (LPA) Tena Herrera conducted an unannounced Plan of Correction (POC) visit to follow up on a citation that was issued on 3/8/24 during the facility's Annual Inspection. LPA met with Rafael Chiu who assisted with the visit.

On 3/8/24 the facility was cited for the following:

80075(f) : 80075-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. LPA received copies of the First Aid certificates for Staff 1&2 on 3/13/24. On today's POC Visit the Proof of Correction (POC) was cleared on 3-13-24.

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. LPA received copy of the LIC9098 with administrator signature stating the regulation has been reviewed and will be followed moving forward, During today’s visit 3/19/24 LPA observed side exit having a lock requiring key to open, same observation as visit conducted on 3/8/24, staff unlocked and removed lock during visit.

The administrator was informed (via phone call during visit) that civil penalties will be assessed for the failure to adhere to the POC. LPA reminded administrator that a locked gate cannot be used to prevent client elopement, as this was the reason staff informed LPA on both visits for the gate being locked.



Exit interview conducted and a copy of this report was provided to Rafael Chiu.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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 1