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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003737
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:51:43 PM

Document Has Been Signed on 03/10/2022 12:51 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JAIRE HOME IVFACILITY NUMBER:
306003737
ADMINISTRATOR:FLERIDA RESURRECCIONFACILITY TYPE:
735
ADDRESS:17831 ARDMORE AVENUETELEPHONE:
(562) 866-2959
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Santiago Barcena - AdministratorTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Administrator Santiago Barcena and explained the reason for the visit. The facility is licensed to serve 4 ambulatory clients. The facility is in a residential area. A tour of the single-story facility included: 4 client bedrooms, 1 staff bedroom, 3 bathrooms, 2 living room, staff office room, kitchen, dining area, laundry area, detached garage, and front yard, and backyard.

LPA Mora conducted the tour with Santiago Barcena and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen and in the refrigerator located in the garage. Sharps were observed locked in a kitchen cabinet. Chemical and cleaning solutions are kept locked in a cabinet above the washing machine and dryer. The First Aid kit is kept locked in hallway cabinet and it is fully stocked with all required items including a current manual. There is a closet in the hallway with clean towels and extra linen. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a cabinet located in the staff office room. All bedrooms have all required furniture, lighting, and bedding. The 3 bathrooms were observed with shower mats. The water temperature was tested and measured between 113.5 and 115.4 degrees F, which is within the required 105-120 degrees F. Fire extinguishers were observed in the kitchen and second living room, and are fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. A carbon monoxide was observed in the dining area and was operable during the visit. The front yard and backyard are clean. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.
LPA reviewed medication for three of the four clients. One client does not have any medications prescribed. Medications are documented properly and given as prescribed. Client and staff files were not reviewed in today’s visit. LPA observed administrator certificate for Santiago Barcena - 6061023735 with an expiration date of 12/05/2023. (CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JAIRE HOME IV
FACILITY NUMBER: 306003737
VISIT DATE: 03/10/2022
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Facility has 30 days supplies of Personal Protective Equipment in the staff office room. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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