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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005238
Report Date: 09/09/2022
Date Signed: 09/09/2022 03:42:31 PM

Document Has Been Signed on 09/09/2022 03:42 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:JUSTIN HOME CAREFACILITY NUMBER:
306005238
ADMINISTRATOR:JOSHUA ESTREVILLOFACILITY TYPE:
735
ADDRESS:5904 EQUADOR WAYTELEPHONE:
(562) 728-7577
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 3DATE:
09/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Tricia EstrevilloTIME COMPLETED:
03:50 PM
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) Jerome Haley conducted an unannounced case management. LPA was greeted, granted entry by staff, and explained the reason for the visit. Staff immediately called Administrator (AD) Joshua Estrevillo via telephone.

The purpose of today's visit was to conduct a Case Management visit to discuss an email sent to LPA Haley regarding a potential client (C1) on a 7 day trial. LPA Haley was informed there was an Unusual Incident Report (LIC624) sent to the Orange County Adult and Senior Care Regional Office regarding this incident as well.

LPA Haley reviewed the referral packet and was provided copies of C1's Physicians report, and medical documents.

LPA Haley interviewed AD Estrevillo via telephone to gather additional details on the incident involving C1.

Further, LPA Haley walked through the facility with staff and observed three clients present during the visit. Clients were observed in the back yard participating in activities at the tables under the fan.

No deficiencies are being cited during today's Case Management visit. An exit interview was conducted and a copy of this report and LIC 811 was provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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 1