306003739-2-27-2024-28-AS-BPEA-D2UT9G-20240227133156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003739
Report Date: 02/27/2024
Date Signed: 02/27/2024 01:32:34 PM

Document Has Been Signed on 02/27/2024 01:32 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 VI		FACILITY NUMBER:	306003739
ADMINISTRATOR:	ARIEL RESURRECCION		FACILITY TYPE:	735
ADDRESS:	9223 FLORA VISTA STREET		TELEPHONE:	(562) 920-5758
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 4		CENSUS: 4	DATE:	02/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ariel Resurreccion - Administrator Irene Genaskey - Program Staff Shiela Masuecos - DSP I & II		TIME COMPLETED:	01:40 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 Shiela Masuecos, Direct Support Professional I & II (DSP I & II) and Angelito Flores, Direct Support Professional I (DSP I) and explained the purpose of the visit. Irene Genaskey, Program Staff arrived at 11:00am and Ariel Resurreccion, Administrator arrived at 12:00pm and assisted LPA with the inspection. The facility is licensed to care for (4) Developmentally Disabled Adults, (2) ambulatory and (2) non ambulatory, ages 18 through 59. All clients at this facility receive case management services from Harbor Regional Center. The facility is a level 4I.

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 maintained. The staff stated that they 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 the Infection Control Plan. Bathrooms have hand soap, paper towel and toilet paper. Staff are adhering to infection control requirements

Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (4) client bedrooms, (3) bathrooms, a living room/activity area, family room/office area, kitchen, dining area, backyard with shaded area, and detached garage. Currently, there are four (4) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, and toilet paper. There is a fire place in the living room that is covered and inaccessible to clients. Kitchen was inspected and LPA observed (1) fire extinguisher mounted on the wall in the kitchen which is operable and was serviced on 03/30/2023. 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 bathroom #1. There are cameras in the front yard only. 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. Readings were 113.5 deg. F in bathroom #1, 114.4 deg. F in bathroom #2 and 113.7 deg F in bathroom #3.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance 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 expires on 03/14/2024. Surety Bond in the amount of $2000 is in effect until 01/11/2026. Last Fire Drill was conducted on 02/02/2024. *****REPORT CONTINUED ON LIC809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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 VI	FACILITY NUMBER: 306003739
	VISIT DATE: 02/27/2024

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Staffing: A total of eleven (11) staff members including the 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. LPA interviewed (4) staff members.
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 03/11/2025.
Client Rights-Information: Client personal rights are posted. Facility provides internet services to all clients and have access to the facility phone. Only (1) client has his own personal cell phone. According to staff, (3) out of (4) clients have their own tablet. LPA interviewed (3) clients, one client is out in the Day program.
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 is sufficient 7-day supply of non-perishable items, but insufficient 2-day food supply. The food is properly stored in the refrigerator and in the extra refrigerator/freezer in the detached garage. 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.
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. Facility has first aid supply but does not have the current first aid manual.
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.

Deficiency cited, and Technical Assistance issued. Exit interview, appeals rights and a copy of this report was provided to the Program Staff, Irene Genaskey.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/27/2024 01:32 PM - It Cannot Be Edited

Created By: Bennette Pena On 02/27/2024 at 01:09 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: 02/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in that LPA observed that 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 clients in care.
	POC Due Date: 03/08/2024
	Plan of Correction
1 2 3 4	Administrator agreed to clean and fix the flooring under the kitchen sink and submit photos for correction 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: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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