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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004596
Report Date: 07/15/2022
Date Signed: 07/15/2022 04:04:07 PM

Document Has Been Signed on 07/15/2022 04:04 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: 3DATE:
07/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Leoncio Canlas, AdministratorTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA), Kathrina Chin conducted an unannounced visit for the purpose of conducting a required annual visit. LPA met with Leoncio Canlas, Administrator and explained the purpose of the visit.

The focus of the visit was Infection Control. The facility was toured with and the following was observed:
Covid signs were posted in the facility and a sanitization station was set up near the front entrance. LPA's temperature was taken upon arrival and a sign in sheet was available. Facility has required Department postings. Restrooms observed contained soap and toilet paper and paper towels. There are some PPE supplies at the facility.

LPA toured the facility inside and out. There are three residents residing in the facility. All residents appeared clean and well taken care of. LPA observed required postings in the facility as well as hand washing signs in the restrooms. All bathrooms observed had ample soap/sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply. LPA reviewed the COVID-19 mitigation plan of the facility.

Smoke detectors and carbon monoxide detectors were operational. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water was measured at 112.2 degrees Fahrenheit. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguishers were mounted and charged.

No deficiencies noted during this visit. An exit interview was conducted and a copy of this report was provided to Leoncio Canlas, Administrator.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2022
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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