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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004596
Report Date: 12/09/2021
Date Signed: 12/09/2021 03:51:53 PM

Document Has Been Signed on 12/09/2021 03:51 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JON ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
306004596
ADMINISTRATOR:LEONCIO CANLASFACILITY TYPE:
735
ADDRESS:3801 LARIAT PLACETELEPHONE:
(714) 770-0892
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 6CENSUS: 4DATE:
12/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Leoncio Canlas, AdministratorTIME COMPLETED:
04:00 PM
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This unannounced site visit was made by Licensing Program Analyst, Kathrina Chin for the purpose of a case management visit- deficiencies. LPA met with Leoncio Canlas, Administrator, Cora Canlas, caregiver, Winnie Greco, caregiver, and Adam Greco, caregiver.

While investigating complaint control number 22-AS-20211203092746, LPA observed that the facility had an insufficient food supplies. There were no fresh fruits and vegetables to meet the three( 3) day supply requirement. There were also no juices at the facility. Also, the facility staff is not following the posted menu. The menu stated for breakfast today consists of eggs and hash browns and juice and milk. There was no ham, bacon or juice in their food supply in order to follow the menu. The staff served one egg and one hash browns for breakfast for the residents today. One resident refused the presented food and was given noodles for breakfast. The facility does not have an insufficient perishable food supplies to meet the 3 day requirement.


Also, a representative from an outside agency observed the door to be locked with a bungee cord on June 15, 2021. Staff admitted that the bungee cord was used in order to keep resident 1(R1) from eloping from the facility. It took four (4) minutes for the staff to open the front door in order for the visitor to gain entry to the facility. There is an auditory alarm at the entrance door.

The following deficiencies are cited today as per Title 22, Division 6 of the California Code of Regulations:

An exit interview was conducted, appeal rights explained and a copy of this report was given to Leoncio Canlas, Administrator.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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Document Has Been Signed on 12/09/2021 03:51 PM - It Cannot Be Edited


Created By: Kathrina Chin On 12/09/2021 at 02:24 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JON ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 306004596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2021
Section Cited
CCR
80076(a)(1)

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Food Services(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served.
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Jon Castro stated that he will instruct staff to purchase food supplies today. Also, receipts will be provided to the licensing agency by 12/10/2021.
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 This requirement is not met as evidenced by: based on facility observation and interview the licensee has insufficient food supplies as there are no fresh fruits and juices at the facility. The facility does not have a 3 day supply of perishables food supplies for 4 residents. This poses an immediate risk to the health and safety of residents in care.
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Type A
12/10/2021
Section Cited
CCR80072(a)(7)

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Personal Rights- (7) Not to be locked in any room, building, or facility premises by day or night. This requirement is not met as evidenced by: based on interviews, the staff 1 admitted that a bungee cord was used on the front door locks in order to prevent the resident to elope from the facility on 6/15/2021.
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Jon Castro, Administrator stated over the telephone that he will call the fire department and find a lock that is allowed by the fire department. Jon Castro stated that staff are no longer using the bungee cord to keep the resident inside.
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 It took four minutes in order to open the front door. This poses an immediate risk to the health and safety of residents in care.
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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:Sheila Santos
LICENSING EVALUATOR NAME:Kathrina Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2021 03:51 PM - It Cannot Be Edited


Created By: Kathrina Chin On 12/09/2021 at 03:26 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JON ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 306004596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2021
Section Cited
CCR
80076(a)(5)

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( 5) Menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the clients or their authorized representatives and the licensing agency upon request.
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Jon Castro said that they have the official menu that is in an excel spreadsheet and he will provide the menu to the facility staff.
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 This requirement is not met as evidenced by: based on facility observation and interview the licensee is not following the menu as they do not have all the necessary food supplies in order to follow the food menu of the day.
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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:Sheila Santos
LICENSING EVALUATOR NAME:Kathrina Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021


LIC809 (FAS) - (06/04)
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