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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004596
Report Date: 07/16/2024
Date Signed: 07/16/2024 12:10:10 PM

Document Has Been Signed on 07/16/2024 12:10 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JON ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
306004596
ADMINISTRATOR/
DIRECTOR:
LEONCIO CANLASFACILITY TYPE:
735
ADDRESS:3801 LARIAT PLACETELEPHONE:
(714) 770-0892
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 6CENSUS: 3DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:38 AM
MET WITH:Leoncio CanlasTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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On July 16, 2024, at 8:38am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Administrator Leoncio Canlas.

The facility is licensed to operate for six (6) ambulatory of which one (1) may be bedridden. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three client (3) bedrooms, two staff (2) bedroom, one office room, four (4) bathrooms, two (2) living areas, lounge, dining room, kitchen, and outside covered patio area.

LPA Kim toured indoor and outdoor of the physical plant with AD Canlas. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All rooms were inspected: Client Room 1, Client Room 2, Client Room 3, Staff Room 1, and Staff room 2. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature measured between 106.5 degrees F and 107.9 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.

LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food supply and emergency water supply was stored in the garage. The facility has two (2) fire extinguisher that were serviced on March 7, 2024, fully charged, and mounted in the dining room and in the garage.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JON ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 306004596
VISIT DATE: 07/16/2024
NARRATIVE
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During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. Fire/Safety drills are done quarterly and last conducted on April 6, 2024. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-770-0892) remains available.

LPA Kim conducted an audit of clients #1-#3 service files, staff #1-#4 personnel files, medication and medication administration review, and Client P&I funds that were all in order and complete. LPA conducted three (3) staff interviews and three (3) client interviews.

A deficiency was cited and a technical violation issued during this inspection visit as per Title 22 Division 6 Chapter 1 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and a copy of appeal rights were provided to Administrator Leoncio Castro.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2024 12:10 PM - It Cannot Be Edited


Created By: Edward Kim On 07/16/2024 at 11:32 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: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed that right gate outside door does not open and close, four window screens that are broken, and the garage sink is dripping when the washer is on. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Licensee states they will fix the outside gate door to open and close, fix/replace four window screens, and fix the garage sink to stop dripping. Licensee will send photos of corrected POC of all items to CCLD via email to edward.kim@dss.ca.gov by POC due date July 26, 2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


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