306003736-2-21-2025-28-AS-DKOI-DE4U8A-20250221142112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003736
Report Date: 02/21/2025
Date Signed: 02/21/2025 02:21:28 PM

Document Has Been Signed on 02/21/2025 02:21 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	JAIRE HOME III		FACILITY NUMBER:	306003736
ADMINISTRATOR/ DIRECTOR:	FLERIDA RESURRECCION		FACILITY TYPE:	735
ADDRESS:	10602 BORWICK STREET		TELEPHONE:	(562) 804-3886
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 4		CENSUS: 3	DATE:	02/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Irene Genaskey, Staff		TIME VISIT/ INSPECTION COMPLETED:	02:30 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 (LPA) Daniel Konishi conducted the required unannounced annual inspection. LPA met with the Staff that is a designated Administrator, Irene Genaskey and explained the reason for the visit. The administrator, Flerida Resurreccion was not present during the visit. The designated Administrator / staff, Irene Genaskey was able to assist with the visit. The facility is licensed to serve three (3) Ambulatory and one (1) non-ambulatory adults ages 18-59. Facility currently has 3 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. 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. Each client bedrooms include all required furniture: a bed, chair, lamps, dressers, and nigh stand, sufficient lighting, and closet space. [Continued in LIC809-C]

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JAIRE HOME III	FACILITY NUMBER: 306003736
	VISIT DATE: 02/21/2025

NARRATIVE

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Physical Plant & Environment Safety [Cont.]: The client’s bathroom is clean, sanitary and in a good working condition. Walls and floors were in good repair. Fireplace is securely closed and inaccessible to clients. Clean towels and bed linens are kept in the hallway closet. Bathroom is clean and operational. Toilets and water faucets worked properly. Showers were free of mold/mildew, had adequate lighting, and there are sufficient toiletries The hot water temperature was tested and bathroom #1 was measured at 110.5 Degrees F and bathroom #2 was measured at 107.8 Degrees F which are within Regulation temperature of 105-120 degrees F. Sharps are locked in a kitchen cabinet and inaccessible to clients. All storage areas for cleaning solutions, toxins, 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 fully charged and last inspected on 1/8/25.

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 2/1/25.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to 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 five (5) staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First Aid, Personnel Record, Health Screening, TB Screening, Employee Rights.and sufficient on-going training. LPA observed First Aid Training Certificate for Staff #1 (S1) is not in file. LPA observed the Health Screening for Staff #4 (S4) is not in file. Administrator Flerida Resurreccion’s Administrator certificate expired on 5/13/2024 but is confirmed as currently pending. Administrator has the required current AIDS/HIV and TB training in file.

Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.

[Continued in LIC809-C]

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JAIRE HOME III	FACILITY NUMBER: 306003736
	VISIT DATE: 02/21/2025

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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, IPP, current Physician's Report, Safeguard Personal Property and Valuables, Pre-admission appraisal/Appraisal Needs & Services Plan, Personal Rights. LPA reviewed three (3) client files with no issues. Facility documents all clients' P & I.

Food Service: The facility has sufficient food supplies of 2-day perishable and a week of non-perishable items. The food is properly stored in the refrigerator (clean and well-maintained). There are no clients with special diets residing at this facility. LPA observed the Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

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. LPA reviewed three (3) client’s medications during today’s visit with no issues. First aid kit was observed and has all required items.

Incidental Medical & Dental: All training is documented in the facility personnel files. Currently there is one (1) client that has a restricted health condition. 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.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit Interview conducted and a copy of the report with appeal rights were provided to the staff / Designated Administrator, Irene Genaskey.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/21/2025 02:21 PM - It Cannot Be Edited

Created By: Daniel Konishi On 02/21/2025 at 01:59 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: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed the Health Screening for Staff #4 (S4) is not in file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2025
	Plan of Correction
1 2 3 4	Administrator will send the Health Screening for Staff #4 (S4) to the LPA by the POC due date.

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 [(observation) (interview) (record review)], LPA observed First Aid Training Certificate for Staff #1 (S1) is not in file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2025
	Plan of Correction
1 2 3 4	Administrator will send the First AId Training Certificate for Staff #1 (S1) to the 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:

Daniel Konishi

LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

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