306005212-10-4-2022-22-AS-JHAY-CJVV2H-20221004160309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005212
Report Date: 10/04/2022
Date Signed: 10/04/2022 04:03:20 PM

Document Has Been Signed on 10/04/2022 04:03 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:	JAYDEN'S HOME CARE		FACILITY NUMBER:	306005212
ADMINISTRATOR:	MANALANG, BRIAN		FACILITY TYPE:	735
ADDRESS:	7853 AZALEA DRIVE		TELEPHONE:	(562) 595-9021
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 2	DATE:	10/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Brian Manalang		TIME COMPLETED:	04:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Administrator (AD) Brian Manalang was present for the visit. AD Manalang has a current administrators certificate that expires 01/20/24. LPA Haley was temperature and symptom checked upon entering the facility.

At 2:20 PM LPA Haley and AD Manalang began the inspection at the entrance of the facility. There were two clients present during the visit. LPA Haley observed a locked closet near the front door with additional PPE supplies: N95 face mask, hand sanitizer, soap, and cleaning supplies. A screening station with a thermometer, surgical mask, and hand sanitizer was observed.

Clients bedrooms were clean, organized, and had all necessary requirements: night stand, chair, lamp and storage space, one of the bedrooms is vacant and used to store miscellaneous items. The client bathroom was clean and organized. Hot water temperature was measured at 105.1 degrees Fahrenheit. In the hallway near the vacant room LPA observed a supply of non-perishable items in a hall cabinet.

The kitchen was clean and organized. LPA Haley observed a supply of emergency water in the hall way as you enter the kitchen. Knives and sharp objects locked in a drawer near the stove. All burners on the stove were operational. All hazardous chemicals were locked under the kitchen sink. LPA Haley observed a 2 day supply of perishable items and a 7 day supply of non-perishable items.

The backyard had clear walkways, free of tripping hazards. Side exit gates were self closing and self latching. LPA Haley observed a shaded patio area with tables and chairs. Several fruit trees were observed. LPA Haley observed a portion of the back yard littered with fallen fruit from the Guava tree. LPA Haley advised AD Manalang the importance of keeping the backyard clean and free of clutter and debris at all times. AD Manalang stated the fallen fruit will be removed no later than Wednesday October 5, 2022.

Continued on LIC809C Dated 10/4/22

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 306005212
	VISIT DATE: 10/04/2022

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The garage is locked and inaccessible to clients at all times. The garage is used for storage of miscellaneous items. No bodies of water were observed during today's visit. All smoke and carbon monoxide detectors were tested and are operational.

An Advisory Notes: Technical Violation was issued for the dirt and debris observed on the window seals in the client bedrooms and the kitchen window.

Deficiencies are being cited during todays visit. An exit interview was conducted and a copy of this report, LIC 9102 (Technical Violation), and appeal rights were provided to Administrator Brian Manalang.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/04/2022 04:03 PM - It Cannot Be Edited

Created By: Jerome Haley On 10/04/2022 at 03:31 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: 10/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087

80087 Buildings 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
1 2 3 4	Based on observation of a cracked livingroom window and acknowledgement from Administor Manalang, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2022
	Plan of Correction
1 2 3 4	The front window in the living room will be repaired or replaced.

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:

Luz Adams

LICENSING EVALUATOR NAME:

Jerome Haley

LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022

LIC809 (FAS) - (06/04)

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