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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005212
Report Date: 10/19/2021
Date Signed: 10/20/2021 07:09:55 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:JAYDEN'S HOME CAREFACILITY NUMBER:
306005212
ADMINISTRATOR:MANALANG, BRIANFACILITY TYPE:
735
ADDRESS:7853 AZALEA DRIVETELEPHONE:
(562) 595-9021
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 2DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Brian ManalangTIME COMPLETED:
12:50 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 Administrator Brian Manalang and explained the reason for the visit.
Upon arrival to the facility, LPAs observed discarded items such as a chair and rugs lying in the front yard.
LPAs observed the screening/ sanitizing station in the entrance of the facility. Facility takes client and staff temperatures daily and documents. Visitors to the facility are screened and temperatures are documented.

At 11:15 AM, LPAs toured the facility with Administrator Manalang. Facility has one client present during today's visit, with one client on an outing. LPAs observed one client participating in a zoom meeting. All client rooms had the required elements as well as restrooms stocked with soap/ sanitizer. At 11:20 AM, LPAs observed discoloration on restroom door and door jamb. 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. Fire extinguisher is mounted and charged. LPAs toured the outside grounds and observed an outside visitation area. Exit gates are unlocked and self latching. At 11:35 AM, LPAs observed loose cement blocks in the yard as well as a door lying on the ground in the side yard. LPAs observed the posted activity schedule including exercise and music therapy. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. Most staff and all clients are vaccinated for Covid-19. Surveillance testing is being conducted twice a week 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 a supply of gowns on-site in case of any covid positive infections.
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 12:00 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: JAYDEN'S HOME CARE
FACILITY NUMBER: 306005212

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(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. LPAs observed discoloration on restroom door and door jamb, discarded items lying in the front yard, a door lying in the side yard and loose cement blocks in the visitation area. This poses a potential health and safety risk to persons in care.
POC Due Date: 11/02/2021
Plan of Correction
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Licensee to repair/ remove/ clean noted items and forward proof to LPA 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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