306003738-2-23-2024-28-AS-BPEA-D2QTJM-20240223134634

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003738
Report Date: 02/23/2024
Date Signed: 02/23/2024 01:47:03 PM

Document Has Been Signed on 02/23/2024 01:47 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 V		FACILITY NUMBER:	306003738
ADMINISTRATOR:	RITCHE ESTRELLA		FACILITY TYPE:	735
ADDRESS:	9630 WALNUT STREET		TELEPHONE:	(562) 920-5643
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 4		CENSUS: 4	DATE:	02/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Flerida Resurreccion - Administrator		TIME COMPLETED:	01:45 PM

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required 1-yr visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Nelia Pascual, Direct Care Staff and explained the purpose of the visit. At 11:00am, Flerida Resurreccion, Administrator arrived and assisted LPA with the inspection. The facility is licensed to care for (4) 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 at the entrance on the the side front door. The staff are not wearing masks and stated that disposable gloves are used to clean and disinfect the high touched surfaces in the common areas. Staff also stated they use gloves when handling food and assisting with medication. Facility still has COVID-19 signage posted on the entrance door and wall. Bathrooms have hand washing signs, 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 (Summa Insurance Services) is in effect and in force with bond amount of $2000. The insurance will expire on 01/11/2026. Last Fire Drill was conducted on 01/05/2024.

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, a family/activity room, a living room, kitchen, dining area, office area, backyard with a swimming pool, detached garage and ADU (Additional Dwelling Unit) in the rear of the property. Currently, there are four (4) clients living in the facility. Facility is Level 4I. 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. Exit doors are free of any obstruction. Backyard was inspected and there were no debris or any obstructions. LPA observed an additional bedroom in the garage that is being used by a staff and the alteration was not reflected on the facility sketch. There is an in ground pool with built in fence and safety gate that was locked and inaccessible to clients. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. There is one (1) fire extinguisher observed mounted on the wall in the dining/kitchen area to be fully charged and was last serviced on 03/30/2023. 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 10:30am, LPA checked the hot water supply and measured at 111.7 deg F in bathroom #1 and 113.9 deg F in bathroom #2. *****REPORT CONTINUED ON LIC809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

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 V	FACILITY NUMBER: 306003738
	VISIT DATE: 02/23/2024

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Staffing: A total of ten (10) 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 is valid and will expire on 05/13/2024. Administrator did not have HIV training proof at the time of visit.
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 stated (1) out of (4) clients has her own personal cell phone and (3) out of (4) clients have their own tablet. LPA conducted client interviews for (2) clients as the other (2) are out in the community.
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 and 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. 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.
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 has a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

Deficiency cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Flerida Resurreccion.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/23/2024 01:47 PM - It Cannot Be Edited

Created By: Bennette Pena On 02/23/2024 at 01:15 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 V	FACILITY NUMBER: 306003738
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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/Licensee did not comply with the section cited above in that LPA observed an additional bedroom in the detached garage being used as a staff bedroom which poses/posed a potential health, safety or personal rights risk to clients in care.
	POC Due Date: 03/08/2024
	Plan of Correction
1 2 3 4	Administrator agreed to revise the facility sketch, secure city permit for the alteration in the garage and contact a fire inspector to determine if a new fire clearance is required. All these documents need to be submitted to CCL/LPA 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: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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