<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004689
Report Date: 01/14/2025
Date Signed: 01/14/2025 11:09:19 AM

Document Has Been Signed on 01/14/2025 11:09 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JIDDE RESIDENTIAL HOME IIIFACILITY NUMBER:
306004689
ADMINISTRATOR/
DIRECTOR:		DEXTER DIZONFACILITY TYPE:
735
ADDRESS:3127 W. TYLER AVENUETELEPHONE:
(714) 828-9637
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 4DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:58 AM
MET WITH:Sarah PineroTIME VISIT/
INSPECTION COMPLETED:
11:45 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) Samer Haddadin 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 and ample space for activities. LPA observed the outside emergency exit to be locked using a wired cable preventing the door to open; LPA advised HM of the emergency exit concern and the wire was taken off and the door was operational.
LPA observed one client present, and three 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 112.4-108.6 degrees Fahrenheit. 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 August23rd,2024. Gas stove, microwave, washer, and dryer were all inspected, and all were operational. 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 two client files and two staff files, and all required documentation was current and up-to-date.
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 were given to HM at the end of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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 2
Document Has Been Signed on 01/14/2025 11:09 AM - It Cannot Be Edited


Created By: Samer Haddadin On 01/14/2025 at 10:59 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: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed the outside emergency exit to be locked using a wired cable which poses potential , safety risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
1
2
3
4
LPA observed house manager remove the wired cable and the door is now functional. POC was corrected on today's visit
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2