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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003737
Report Date: 03/17/2023
Date Signed: 03/17/2023 04:27:50 PM

Document Has Been Signed on 03/17/2023 04:27 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 IVFACILITY NUMBER:
306003737
ADMINISTRATOR:FLERIDA RESURRECCIONFACILITY TYPE:
735
ADDRESS:17831 ARDMORE AVENUETELEPHONE:
(562) 866-2959
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
03/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Administrator, Clarisse MarcelinoTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Jesusa Bayacal, Direct Service Professional (DSP) and explained the purpose of the visit. Administrator Clarisse Marcelino arrived at 11:00am and assisted LPA with the inspection. The facility is licensed to care for Developmentally Disabled Adults, ages 18 through 59, ambulatory only. All clients residing at this facility receive case management services provided by Harbor Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located near the front door. The staff are wearing masks throughout their shift and disposable gloves are used to clean and disinfect the high touched surfaces in the common areas. DSP Jesusa Bayacal did not screen the LPA upon entry, and was prompted to conduct the screening by the LPA. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements. The Infection Control Plan did not list the name of the Infection Preventionist at the facility.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance for four (4) ambulatory clients is in place. Surety Bond (Summa Insurance Services) is in effect and in force with bond amount of $2000. The insurance will expire on 08/03/2025. Last Fire Drill was conducted on 03/04/2023.

Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains four (4) client bedrooms, one (1) staff bedroom, two (2) full bathrooms, one (1) powder room, a family room, a living room, kitchen, dining area, office area, backyard, and detached garage. Currently, there are four (4) clients living in the facility. Facility is Level 4A. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. However, Bathroom #1 has leaking faucet in the shower and LPA observed mold and mildew on the walls and ceiling. Bathroom #2 has mold and mildew on the walls and ceiling. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and LPA observed old and broken wooden furniture on the side yard, behind the detached garage. Detached garage was inspected and LPA observed that the garage is being used as a staff bedroom. There is a bunk bed, a table, chair and personal belongings in the area. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. There are two (2) fire extinguishers observed to be fully charged and both were last serviced on April 18, 2022. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. At 11:30am, hot water supply measured 115.4 in the kitchen, 116.6 in bathroom #1, 115.9 in bathroom #2 and 116.1 in bathroom #3.

*****REPORT CONTINUED ON LIC809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JAIRE HOME IV
FACILITY NUMBER: 306003737
VISIT DATE: 03/17/2023
NARRATIVE
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Staffing: A total of four (4) staff members provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.

Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate expired on 9/11/2020 and does not have a valid/current certificate. Administrator submitted renewal in September 2022, but has not thoroughly checked the renewal status. Administrator will submit 40 CEUs taken in 2022, renewal payment receipt, credit card statement showing amount paid to LPA by POC due date. Administrator did not have HIV training proof at the time of visit. Administrator will submit to CCLD by POC due date.

Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Administrator also stated (2) out of (4) clients have their own personal cell phones and (2) out of (4) clients have their own tablet. LPA did not conduct client interviews during the visit as all (4) clients were out at the time.



Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: There are sufficient food supplies of 2-day perishable but insufficient supply of 7-day 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. Pesticides and cleaning supplies are kept away from the food preparation areas (locked in the upper cabinet above the laundry machines). Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services The medications are centrally stored and in their original containers. Medications were reviewed for C1-C4 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.

*****REPORT CONTINUED ON LIC809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JAIRE HOME IV
FACILITY NUMBER: 306003737
VISIT DATE: 03/17/2023
NARRATIVE
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Incidental Medical Services: Per the Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility does not have a complete Emergency Disaster and Mass Casualty Plan. LPA provided a copy of the Care Tool standards covering Health and Safety Code 1565 and California Code of Regulation 80023 to the Administrator.

Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Clarisse Marcelino.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 03/17/2023 04:27 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/17/2023 at 03:31 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 IV
FACILITY NUMBER: 306003737

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)(1)(A)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.  (1) The Infection Control Plan shall include all of the following:  (A) Identification of a staff position to perform the duties of an Infection Preventionist for the facility. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on interview, record review, the Administrator did not comply with the section cited above in that the Infection Control Plan did not list the name of the Infection Preventionist at the facility which posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 03/31/2023
Plan of Correction
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The Administrator will submit an updated infection Control Plan listing the name of the individual assigned as the Infection Preventionist. Administrator will also review the PIN related to the plan and submit a signed statement that the PIN has been read, reviewed and understood on or before the POC due date.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the Administrator did not comply with the section cited above in which LPA observed old and broken wooden furniture on the side yard, behind the detached garage which posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 03/31/2023
Plan of Correction
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The Administrator will clean and remove the broken wooden furniture and submit photos of the cleaned area to CCLD on or before the 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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 03/17/2023 04:27 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/17/2023 at 03:31 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 IV
FACILITY NUMBER: 306003737

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator did not comply with the section cited above in which LPA observed that bathroom #1 has leaking faucet in the shower and mold/mildew on the walls and ceiling. Bathroom #2 has mold and mildew on the walls and ceiling also which poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 03/31/2023
Plan of Correction
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Administrator will submit photos of both bathrooms had been repaired and proof that the mold/mildew had been removed. Administrator will also submit receipts or service reports/invoices that bathrooms #1 and 2 have been repaired on or before the POC due date.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in that the Administrator did not have HIV training proof at the time of visit which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 03/31/2023
Plan of Correction
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Administrator will submit proof of current HIV training to CCLD on or before the 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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 03/17/2023 04:27 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/17/2023 at 03:31 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 IV
FACILITY NUMBER: 306003737

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(12)(B)1
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: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that the Administrator certificate expired on 9/11/2020 and does not have a valid/current certificate. Administrator submitted renewal in September 2022, but has not thoroughly checked the renewal status which poses/posed a potential health, safety or personal rights risk to clients in care.

which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Administrator will submit proof that the renewal had been submitted to CCLD and the CEUs taken on or before the POC due date.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, the Administrator did not comply with the section cited above in that the 7-day nonperishable food supplies are insufficient which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Admiinistrator will purchase non perishable supplies and submit receipts of the purchase as well as photos of the non persihable items to CCLD on or before the 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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 03/17/2023 04:27 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/17/2023 at 03:31 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 IV
FACILITY NUMBER: 306003737

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in that there is no Eemergency and Disaster Plan filed in the facility at the time of visit which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 03/31/2023
Plan of Correction
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Administrator will ensure that a copy of the Emergency and DIsaster plan is filed and kept at the facility at all times. Administrator will submit a current and complete Emergency and Disaster Plan to CCLD on or before the POC due date.
Type B
Section Cited
CCR
85087(a)(3)(A)
85087 Buildings and Grounds
(a) In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements:
(3) No room commonly used for other purposes shall be used as a bedroom for any person.
(A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings.


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview,record review, the Administrator did not comply with the section cited above in that LPA observed that the garage is being used as a staff bedroom which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 03/24/2023
Plan of Correction
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Administrator will clean out the garage and remove the bunkbed, table, chairs and personal belongings of the staff staying there. Administrator will submit photos of the cleaned out garage on or before the 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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 03/17/2023 04:27 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/17/2023 at 03:56 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 IV
FACILITY NUMBER: 306003737

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80086(a)
80086 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the Administrator did not comply with the section cited above in that the detached garage is being used as a staff bedroom. LPA observed bunkbeds, table and chairs and personal belongings of the staff. Administrator did not notify CCLD or Fire or Building Inspector of the said alteration to the garage which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 03/20/2023
Plan of Correction
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2
3
4
Administrator will ensure that staff working in the facility do not use the detached garage as bedroom for staff. Administrator will submit photos that the garage has been cleaned out, personal belongings removed. Training on use of facilities will be conducted and a copy of the training signed by staff will be submitted to CCLD by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023


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