306003738-2-28-2025-28-AS-DKOI-DEC3MU-20250228172256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003738
Report Date: 02/28/2025
Date Signed: 02/28/2025 05:23:10 PM

Document Has Been Signed on 02/28/2025 05:23 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 V		FACILITY NUMBER:	306003738
ADMINISTRATOR/ DIRECTOR:	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:	02/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:30 PM
MET WITH:	Irene Genaskey, Designated Administrator, Staff		TIME VISIT/ INSPECTION COMPLETED:	05:40 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 an unannounced Required 1-yr visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by S1 and explained the purpose of the visit. Irene Genaskey Designated Administrator / staff arrived shortly after and assisted LPA with the inspection.

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

Infection Control: The facility's Infection Control Plan is in place. Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located at the entrance on 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: 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. A fire clearance for four (4) ambulatory clients is in place. Last Fire Drill was conducted on 01/05/2024.

Physical Plant/Environment Safety: The facility is a single-story 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. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, nightstand, light, chair, and sufficient closet space.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

Document Has Been Signed on 02/28/2025 05:23 PM - It Cannot Be Edited

Created By: Daniel Konishi On 02/28/2025 at 05:02 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: 02/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80068(a)

Admission Agreements

(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, Client #3 (C3’s) Admission Agreement was not in file. which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2025
	Plan of Correction
1 2 3 4	Administrator will send a copy of the Client #3 (C3's) Admission Agreement to the LPA by the POC due date.

Type B

Section Cited

CCR

85068.2(b)(1)(C)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, Client #1 (C1) and Client #2 (C2's) updated Physician’s Report was not in file. which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2025
	Plan of Correction
1 2 3 4	Administrator will send Client #1 (C1) and Client #2(C2's) updated Physician's Repor to the LPA by 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:

Daniel Konishi

LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

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 V	FACILITY NUMBER: 306003738
	VISIT DATE: 02/28/2025

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
26
27
28
29
30
31
32

Physical Plant/Environment Safety [Cont.]: Water temperature readings measured hot water in the bathroom at 114.8 degrees F which is within the required 105 - 120 degrees F. The client’s bathroom is clean, sanitary and in a good working condition. Walls and floors were in good repair. Clean towels are kept in the hallway closet and new bed linens are currently in an unoccupied client bedroom’s 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 that are accessible to clients. 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. Fireplace is securely closed and inaccessible to clients. 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. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility.

Staffing: A total of six (6) 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: 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. 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: Client personal rights are posted. Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.

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), Individual Program Plan (IPP), Clients Personal Rights observed. However, based on LPA record review, Client #1 (C1) and Client #2 (C1) updated Physician’s Report was not in file. Client #3 (C3’s) Admission Agreement was not in file.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

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 V	FACILITY NUMBER: 306003738
	VISIT DATE: 02/28/2025

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
26
27
28
29
30
31
32

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 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: Based on record review, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan readily accessible. Emergency Fire Drill was conducted on 1/3/2025. Emergency Disaster/ Earthquake Drills was conducted on 1/3/2025.

Emergency Intervention: The facility does not use any restraint on clients.

LPA was unable to conduct staff and client interviews during the visit so LPA will conduct staff and client interviews at a later date.

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: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4