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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003739
Report Date: 04/18/2023
Date Signed: 04/18/2023 03:09:30 PM

Document Has Been Signed on 04/18/2023 03:09 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 VIFACILITY NUMBER:
306003739
ADMINISTRATOR:RITCHE ESTRELLAFACILITY TYPE:
735
ADDRESS:9223 FLORA VISTA STREETTELEPHONE:
(562) 920-5758
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Clarisse MarcelinoTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA was screened and allowed entry by Angelito Flores/Direct Support Professional(DSP). LPA explained the purpose of today's visit. At 11:00am, Administrator Clarisse Marcelino arrived and assisted LPA with the inspection.
The facility is licensed to serve 2 ambulatory and 2 non ambulatory clients ages 18 through 59. Current census is (4), (3) ambulatory and (1) non ambulatory. 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: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies. Facility has an Infection Control Plan and Mitigation 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.

Physical Plant & Environment Safety: This facility consists of (4) bedrooms (2) full bathrooms and half (1/2) bathroom, family room, living/activity room, kitchen, dining area, and detached garage. Smoke alarms were tested and operable. Fire extinguisher appeared to be full and was last serviced on 03/30/2023. Carbon monoxide tested and operable. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water supply measured 118.1* in the kitchen (@ 11:50am), 117.3* in bathroom #1, 117.9* in bathroom #2 and 118.2* in half (1/2) bathroom.

Operational Requirements: The fire clearance is approved for (2) ambulatory and (2) non ambulatory clients. Last Fire Drill was conducted on 04/07/2023.

Staffing: There is sufficient staffing at the facility. The Administrator, Clarisse Marcelino is still waiting for her Certificate. Renewal along with CEU's were submitted on 9/06/2022. Administrator's HIV/AIDS Training Certificate shows completion on 6/24/2022. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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 VI
FACILITY NUMBER: 306003739
VISIT DATE: 04/18/2023
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Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, S1 and S2. Staff have sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting, Client Rights and Zero Tolerance.

Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Per Administrator, none of the clients have their own personal cell phones. Per Administrator, (2) out of (4) clients have their own tablet, (1) provided by the Adult Day Program and (1) purchased by the client personally.

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 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. Pesticides and cleaning supplies are kept away from the food preparation areas (locked outside in the shed). Plates, cups and utensils are kept cleaned and stored properly. LPA observed that the cabinet under the kitchen sink was not kept clean and not free of litter or insects/bugs. Additionally, the dishwasher was broken and inoperable.

Health Related Services The medications are centrally stored and in their original containers. LPA reviewed medication for C1 through C4. 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. No discrepancies noted.

Incidental Medical Services: Per 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. Exit interview, appeals rights and a copy of this report was provided to Administrator, Clarisse Marcelino
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/18/2023 03:09 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/18/2023 at 01:55 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 VI
FACILITY NUMBER: 306003739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, interview, the Administrator did not comply with the section cited above in which there are old, worn out furniture, old/inoperable boat and debris in the backyard behind the shed and next to the garage that are potential hazards which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/02/2023
Plan of Correction
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Administrator will submit photos of the areas behind the shed, and around the detached garage to show that the debris, old, worn out furniture and old/inoperable boat had been disposed and cleared on or before the POC due date.
Type B
Section Cited
CCR
80076(a)(17)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

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 the cabinet under the kitchen sink was not kept clean and not free of litter or insects/bugs. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2023
Plan of Correction
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Administrator will submit photos of the cleaned/cleared out cabinet under the kitchen sink 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: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
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