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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005186
Report Date: 10/19/2021
Date Signed: 10/20/2021 07:09:01 AM

Document Has Been Signed on 10/20/2021 07:09 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:J AND P HOMES ORCHIDFACILITY NUMBER:
306005186
ADMINISTRATOR:SANTOS, MELBA MFACILITY TYPE:
735
ADDRESS:7971 ORCHID DRIVETELEPHONE:
(714) 296-5135
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 6DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Grace Dagdag and Melba SantosTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Jerome Haley conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Caregiver Grace Dagdag and explained the reason for the visit. Administrator Melba Santos arrived during the visit. Administrator Santos has a current administrator certificate expiring on 06/30/2022.

At 2:00 PM, LPAs toured the facility with Administrator Santos. Facility has six clients present during today's visit. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPAs observed the screening/ sanitizing station in the entrance of the facility. Facility takes client and staff temperatures daily and documents. LPAs observed the visitor screening area as well as documented temperatures for visitors. Facility has covid precaution postings as well as all required department postings. The facility mitigation plan has been completed and approved. LPAs observed adequate emergency food and water as well as the first aid kit. First aid kit contained all required items. LPAs observed locked medication drawer. LPAs observed unsecured scissors in an unlocked drawer. Fire extinguishers are mounted and charged. LPAs toured the outside grounds and observed the outside shaded visitation area. Exit gates are unlocked and self latching. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. All staff and clients are vaccinated for Covid-19. Facility is conducting weekly surveillance testing on staff. LPAs reviewed all client files and all contained required documentation including updated emergency information.
LPA consulted with Administrator on the importance of maintaining an ample supply of N95 masks as well as serving appropriate food for clients in care. Additionally, LPA spoke with Administrator regarding posting the "Let Us No" poster in regulation size, 20" X 26."
Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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 10/20/2021 07:09 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 10/19/2021 at 02:36 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: J AND P HOMES ORCHID
FACILITY NUMBER: 306005186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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. LPAs observed unsecured scissors in an unlocked kitchen cabinet. This poses an immediate health and safety risk to persons in care.
POC Due Date: 10/20/2021
Plan of Correction
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Staff secured scissors during the visit. Licensee to submit a written statement of understanding of the regulation cited by POC due 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2021


LIC809 (FAS) - (06/04)
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