306004596-7-15-2025-22-AS-EKIM-DJLSAF-20250715134215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004596
Report Date: 07/15/2025
Date Signed: 07/15/2025 01:42:24 PM

Document Has Been Signed on 07/15/2025 01:42 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 HOME		FACILITY NUMBER:	306004596
ADMINISTRATOR/ DIRECTOR:	LEONCIO CANLAS		FACILITY TYPE:	735
ADDRESS:	3801 LARIAT PLACE		TELEPHONE:	(714) 770-0892
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92835
CAPACITY: 6		CENSUS: 3	DATE:	07/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Caregiver Corazon Canlas		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On July 15, 2025, at 8:00 AM, 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 Caregiver (CG) Corazon Canlas. LPA spoke with Administrator (ADMIN) Leoncio Canlas who stated he could not attend today’s visit. ADMIN Canlas stated that CG Canlas could sign on behalf of the facility. The facility is licensed to operate for six (6) ambulatory of which one (1) may be bedridden. The facility is a single-story building located in a residential neighborhood. It consists of the following: three (3) client bedrooms, one (1) staff bedrooms, one (1) vacant bedroom, one office room, four (4) bathrooms, two (2) living areas, lounge, dining room, two (2) storage areas next to a detached building, detached building as a staff bedroom, kitchen, and outside covered patio area. LPA Kim toured indoor and outdoor of the physical plant with CG Canlas. There were no bodies of water or obstructions on the premises. The detached building has two storage areas next to it with fences. The building is listed as an office according to the facility sketch. LPA observed that the facility is utilizing it as a staff bedroom. 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, and vacant room. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature measured between 110.5 degrees F and 115.1 degrees F. A comfortable temperature of 75 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 07/15/2025

NARRATIVE

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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 were stored in the garage. The facility has two (2) fire extinguishers that were serviced on February 28, 2025, fully charged, and mounted in the dining room and in the garage.

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 was last conducted on July 1, 2025. The carbon monoxide detectors were operable and in working order. Two out of eleven smoke detectors were not operable in the facility. The non-operable smoke detectors were in client bedroom #2 and a vacant bedroom. A working telephone (714-770-0892) remains available.

LPA Kim conducted an audit of three (3) client files, four (4) staff personnel files, medication and medication administration review, and Client P&I funds that were all in order and complete. LPA conducted interviews two (2) client interviews.

Deficiencies were cited during this inspection visit as per Title 22 Division 6 Chapter 1 of the California Code of Regulations. Facility utilized detached building in the backyard as a staff room where facility sketch lists it as an office. Client bedroom #2 and vacant bedroom had inoperable smoke detectors.

An exit interview was conducted, and a copy of this report, LIC811, and a copy of appeal rights were provided to Caregiver Corazon Canlas.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/15/2025 01:42 PM - It Cannot Be Edited

Created By: Edward Kim On 07/15/2025 at 01:08 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: 07/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in two out of eleven smoke detectors. LPA observed client room #2 and vacant bedroom smoke detectors were not operable during the visit. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2025
	Plan of Correction
1 2 3 4	Licensee states they will fix the smoke detectors in client room #2 and the vacant bedroom. They will send proof of completed POC to CCLD via email to edward.kim@dss.ca.gov by POC due date July 16, 2025.

Type A

Section Cited

CCR

85087(a)(3)(A)

Building and Grounds

(3) No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed a detached building being used a staff bedroom. In the facility sketch, it is listed as an office. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2025
	Plan of Correction
1 2 3 4	Licensee states they will remove the bed and all personal belongings out of the detached building. They will send proof of completed POC to CCLD via email to edward.kim@dss.ca.gov by POC due date July 16, 2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:

	Edward Kim
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

LIC809 (FAS) - (06/04)

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