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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003737
Report Date: 02/16/2024
Date Signed: 02/16/2024 03:19:09 PM

Document Has Been Signed on 02/16/2024 03:19 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:ARIEL RESURRECCIONFACILITY TYPE:
735
ADDRESS:17831 ARDMORE AVENUETELEPHONE:
(562) 866-2959
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
02/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Irene Genaskey - Designated AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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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 Yolanda Schuver, Direct Care Staff and explained the purpose of the visit. Administrator Irene Genaskey arrived at 10:30am 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. Covid 19 signs are still posted at the main entrance door. The staff use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements.


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. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid and will expire on 03/14/2024. Surety Bond (Western Surety Company) 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 02/03/2024 and held on a monthly basis.

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) staff bathroom, 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 contained hygiene supplies including liquid soap, paper towels, and toilet paper, however, did not have non-skid mats. LPA also observed the presence of mold an mildew around the bath tub in bathroom #1. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. Laundry area is in the kitchen. LPA observed unlocked cabinet doors above the laundry machines where disinfectants, cleaning supplies and toxic substance are stored, which are accessible to clients. Kitchen knives are kept in a locked cabinet under the kitchen sink. There are two (2) fire extinguishers observed to be fully charged and both were last serviced on March 30, 2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. There are no cameras in the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. *****REPORT CONTINUED ON LIC809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JAIRE HOME IV
FACILITY NUMBER: 306003737
VISIT DATE: 02/16/2024
NARRATIVE
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Staffing: A total of five (5) staff members including the designated Administrator 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-Training: LPA reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training were reviewed. Staff #1 (S1) did not have a current first aid training on file. Staff #2 did not have completed health screening. The Administrator is out of the country and the Designated Administrator Irene Genaskey does not have an Administrator certificate and has not completed the required Administrator classes/courses. Designated Administrator presented her HIV/AIDS training completed on 02/01/2024.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Designated Administrator stated (4) out of (4) clients have their own personal cell phones and (2) out of (4) clients have their own tablet/IPad. LPA conducted (3) client interviews during the visit. One client is staying with a family member during the visit.
Food Service: There are sufficient food supplies of 7-day non-perishable items, but insufficient supply of 2-day perishables. Staff purchased some items like fresh produce and dairy/deli during the visit. 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. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
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.
Health Related Services The medications are centrally stored and in their original containers. Medications were reviewed for C1-C3 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. Some medications are bubbled packed and some are in tight-fitting bottles.
Incidental Medical Services: Per the Designated Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

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

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 02/16/2024 03:19 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/16/2024 at 02:28 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: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in which LPA observed unlocked cabinet doors where disinfectants, cleaning supplies and scissors are stored which are accessible to clients which are accessible which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 02/17/2024
Plan of Correction
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During the visit, staff #3 (S3) secured and locked the upper cabinets to make it inaccessible to clients. Designated Administrator agreed to train all the staff about clients safety and keep the disinfectants, cleaning solutions inaccessible to clients. ***Deficiency cleared during the visit.***
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/16/2024 03:19 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/16/2024 at 02:28 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: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(f)
Administrator Qualifications and Duties
(f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065, who shall be capable, of, and responsible and accountable for, management and administration of the facility in compliance with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the Administrator did not comply with the section cited above in that the designated Administrator does not have a valid Administrator certificate due to the required classes/courses has not been completed yet which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 03/01/2024
Plan of Correction
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The Administrator will submit a signed statement that he read, reviewed and understood Title 22 Regs. 85064. Licensee shall designate a qualified Administrator who completed the required courses to be responsible in the facility in his absence. These documents along with a copy of the designated Administrator's certificate shall be submitted to LPA/CCL on or before the POC due date.
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
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Based on interview, record review, the Administrator did not comply with the section cited above in which Staff #2 did not have the required health screening on file which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 03/01/2024
Plan of Correction
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Administrator will submit a copy of the health screening for S2 to LPA/CCL 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: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 02/16/2024 03:19 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/16/2024 at 02:28 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: 02/16/2024

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
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Based on record review, the Administrator did not comply with the section cited above in that Staff #1 (S1) does not have evidence of current first aid training which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 03/01/2024
Plan of Correction
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Administrator will submit a copy of the current/valid first aid certificate for S1 to LPA/CCL on or before the POC due date.
Type B
Section Cited
CCR
80023(b)(1)
Disaster & Mass Casualty Plan
(b) The plan shall be subject to review by the licensing agency and shall include: (1) Designation of administrative authority and staff assignments.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the Administrator did not comply with the section cited above in that the Administrator is out of the country and did not submit Designation of Facility Responsibility to CCL to notify who the contact/Administrator responsible for the facility in his absence which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 03/01/2024
Plan of Correction
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The Administrator will submit signed statements that he read, reviewed and understood (a) Title 22 Regs. 80023 and (b) Administrator will submit LIC308/Designation of Facility Responsibility to LPA/CCL indicating the absence dates in the future. These documents will be submitted to LPA/CCL 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: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024


LIC809 (FAS) - (06/04)
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