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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004689
Report Date: 02/01/2024
Date Signed: 02/01/2024 01:09:50 PM

Document Has Been Signed on 02/01/2024 01:09 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: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:
02/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sarah Pinero
Odilon Pinero		TIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with House Manager (HM) Sarah Pinero and explained the purpose of the inspection.

During the inspection LPA and HM conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with six bedrooms, three bathrooms, and unattached two-car garage. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. The back yard has a shaded sitting area. LPA observed two clients present, and two additional clients were away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 110.4-113.0 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag dated 9/07/23. Gas stove, microwave, washer, and dryer were all inspected. LPA observed a kitchen windowsill dripping water above an electrical outlet due to water leaking through the window from the rain outside. Staff stated they had unplugged microwave from the outlet as a safety precaution; a Deficiency was cited on today’s date. Sharps were observed locked in a kitchen cabinet. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked. LPA reviewed four client files and two staff files. LPA interviewed staff and clients present.

Based on the observations made during today’s inspection, one deficiency is being 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: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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 02/01/2024 01:09 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 02/01/2024 at 12:41 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: JIDDE RESIDENTIAL HOME III
FACILITY NUMBER: 306004689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024

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
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Based on observation, the licensee did not comply with the section cited above. LPA observed a kitchen windowsill dripping water above an electrical outlet due to water leaking through the window from the rain outside, which poses an immediate safety risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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HM stated the landlord has been made aware of the rain entering through the kitchen window. HM stated she will follow up with landlord on today's date and will provide LPA with paperwork related to repairs via email by POC date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024


LIC809 (FAS) - (06/04)
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