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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004596
Report Date: 12/07/2023
Date Signed: 12/07/2023 08:40:21 AM

Document Has Been Signed on 12/07/2023 08:40 AM - 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: 3DATE:
12/07/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
07:50 AM
MET WITH:Leoncio CanlasTIME COMPLETED:
08:55 AM
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This unannounced Case Management – Health Checks inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check. LPA met with Administrator (AD) Leoncio Canlas and explained the purpose of the inspection.

During the inspection, LPA and AD toured the facility. LPA observed there were 2 staff and 3 clients present. LPA conducted health and safety checks on the 3 clients present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food, the electricity and water were running, the facility had soap and paper towels, and the medications, knives, and toxins were property stored. LPA requested and reviewed copies of the resident roster, staff roster, and staff schedule. LPA inspected client money and ledgers for 3 clients.

During the inspection, LPA and AD observed the following. In the garage, the stand-alone lockable storage cabinet used to store toxins is damaged. The 4 sides are no longer firmly attached to each other and the cabinet wobbles and could collapse in the near future.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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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Document Has Been Signed on 12/07/2023 08:40 AM - It Cannot Be Edited


Created By: Sean Haddad On 12/07/2023 at 08:32 AM
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: 12/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/04/2024
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by:
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Licensee stated they will replace the cabinet, train staff on reporting broken items, and submit proof to LPA by POC due date.
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Based on observation, the licensee did not ensure the stand-alone lockable storage cabinet used to store toxins in the garage is in good repair, which poses a potential safety risk to persons 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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
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