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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004689
Report Date: 02/22/2024
Date Signed: 02/22/2024 11:40:31 AM

Document Has Been Signed on 02/22/2024 11:40 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:JIDDE RESIDENTIAL HOME IIIFACILITY NUMBER:
306004689
ADMINISTRATOR:DEXTER DIZONFACILITY TYPE:
735
ADDRESS:3127 W. TYLER AVENUETELEPHONE:
(714) 828-9637
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 4DATE:
02/22/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Monette MenbiolaTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced Plan of Correction (POC) inspection for the purpose of clearing deficiency previously cited during annual required inspection on 2/01/24. LPA was greeted and granted entry by Staff Monette Menbiola and explained the purpose of the inspection.

Deficiency previously cited was due to kitchen windowsill dripping water above an electrical outlet, as water leaked through the window frame from the rain outside. On 2/09/24, LPA conducted on unannounced POC inspection, and observed the window frame and windowsill had not been repaired. LPA spoke with Licensee by phone, who stated the window would be replaced entirely and the new window had been ordered the day prior. Per Licensee, they anticipated the window would be replaced in one week. LPA informed Licensee an additional unannounced inspection would be conducted at the time. Licensee stated they understood.

On today's date, LPA observed window frame and windowsill had not been repaired. At approximately 11:20 a.m. LPA spoke with Administrator (AD) Dexter Dizon by phone, who stated window has not arrived and they do not have an anticipated date for when repairs will take place.

Based on today’s observations, one deficiency is being re-cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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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Document Has Been Signed on 02/22/2024 11:40 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 02/22/2024 at 11:21 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: JIDDE RESIDENTIAL HOME III
FACILITY NUMBER: 306004689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
80087(a)

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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:
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AD stated they would seek a different contractor for window repairs and have repairs completed by POC date. LPA will conducted an additional inspection at that time to verify POC.
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Based on observation, the licensee did not comply with the section cited above. LPA observed kitchen windowsill dripping water above an electrical outlet due to water leaking through the window frame from the rain outside, which poses an immediate 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:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
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