306005230-7-18-2022-22-AS-RQUZ-CGFTM7-20220718145036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005230
Report Date: 07/18/2022
Date Signed: 07/18/2022 02:50:59 PM

Document Has Been Signed on 07/18/2022 02:50 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:	JAN'S HOUSE LLC		FACILITY NUMBER:	306005230
ADMINISTRATOR:	JOINER, KERRY		FACILITY TYPE:	740
ADDRESS:	16970 MOUNT EDEN ST		TELEPHONE:	(714) 486-2959
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 6	DATE:	07/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:58 AM
MET WITH:	Gina Elliott, Caregiver and Kerry Joiner, Licensee/Administrator, Terry Joiner, Licensee		TIME COMPLETED:	02:50 PM

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On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by Caregiver Enrico Novero. LPA explained the nature of the visit. Licensee/Administrator (L/AD) Kerry Joiner and Licensee(L) Terri Joiner arrived shortly after. Facility indicated screening all incoming visitors prior to entering the facility. Facility is licensed to provide services to Age range 60 and over, 6 Non-Ambulatory residents, and has a Hospice Waiver for 4 residents. Facility currently providing services to 1 resident on hospice. (L/AD) Kerry Joiner has an Administrator certificate with expiration date of June 28, 2022. (L/AD) Kerry Joiner indicated already completing Administrator renewal process and awaiting new certificate. L/AD Kerry Joiner agreed to submit new administrator certificate to CCL upon receiving it.

On or about 1:22pm, LPA Rosie Quiroz along with (L/AD) Kerry Joiner began the tour of the inside and outside of the facility. There are six (6) residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed three of six residents in their bedroom resting, and three of six residents observed to be in living room area watching television supervised by caregivers. LPA Quiroz interacted and interviewed with residents during today's visit. Six of six residents appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature recorded to be 77 degrees Fahrenheit.

All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within 112.2-115.6 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area and kitchen area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating and shaded area for residents and visitor's enjoyment in backyard area. CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022

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: JAN'S HOUSE LLC	FACILITY NUMBER: 306005230
	VISIT DATE: 07/18/2022

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The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on June 2, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated June 2, 2021.

LPA Quiroz was informed that all residents and staff have had their COVID-19 vaccinations and first booster. Facility indicated to be recording resident's temperatures daily.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. An Advisory Note-Technical Violation LIC 9102 assessed during today's inspection visit.

During today's visit, LPAs provided Consultation on Title 22 and COVID-19 Infection control throughout today's visit.

This report was reviewed with (L/AD) Kerry Joiner and (L) Terri Joiner, and a copy of this report, LIC 9102 Technical Violation and LIC 811 Confidential names were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022

LIC809 (FAS) - (06/04)

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