<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004689
Report Date:
02/15/2022
Date Signed:
02/15/2022 11:16:23 AM
Document Has Been Signed on
02/15/2022 11:16 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:
JIDDE RESIDENTIAL HOME III
FACILITY NUMBER:
306004689
ADMINISTRATOR:
DEXTER DIZON
FACILITY TYPE:
735
ADDRESS:
3127 W. TYLER AVENUE
TELEPHONE:
(714) 828-9637
CITY:
ANAHEIM
STATE:
CA
ZIP CODE:
92801
CAPACITY:
6
CENSUS:
4
DATE:
02/15/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Sarah Pinero
TIME COMPLETED:
11:42 AM
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
Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the annual required inspection (mitigation). LPA was screened for Covid-19 symptoms and granted entry by staff. LPA explained the reason for the visit. LPA and staff toured the facility. LPA observed that all bedrooms were clean and organized. Clients had the required furnishings. All bed linens were clean. All smoke detectors/carbon monoxide detectors tested operational. LPA inspected the first aid kit. The first aid kit had all the required elements. LPA and staff toured the kitchen. LPA observed 2 day perishable and 7 day non-perishable food supply on hand. The knives and sharp objects are kept locked in a kitchen cabinet. Medication is kept locked in a kitchen cabinet. The kitchen is clean and organized. LPA and staff toured the backyard. The exit gates are operational. No obstacles or hazards observed. No bodies of water observed. The shed in the backyard is kept locked and inaccessible to clients. The shed is used to store supplies and bicycles. LPA and staff toured the garage. The garage is detached and used for storage and holds the washing machine and dryer. The garage is kept locked and inaccessible to clients. There is an extra refrigerator in the garage which has extra food. Facility mitigation plan was approved on 4/8/21. No deficiencies are being cited as a result of this visit. An exit inter view was conducted and a copy of the report provided.
SUPERVISORS NAME
:
Luz Adams
LICENSING EVALUATOR NAME
:
Joseph Alejandre
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/15/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1