306005238-10-4-2022-22-AS-JHAY-CJVS77-20221004133703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005238
Report Date: 10/04/2022
Date Signed: 10/04/2022 01:37:08 PM

Document Has Been Signed on 10/04/2022 01:37 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 CARE		FACILITY NUMBER:	306005238
ADMINISTRATOR:	JOSHUA ESTREVILLO		FACILITY TYPE:	735
ADDRESS:	5904 EQUADOR WAY		TELEPHONE:	(562) 728-7577
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:	11:55 AM
MET WITH:	Tricia Estrevillo		TIME COMPLETED:	01:45 PM

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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. LPA Haley as temperature checked and screened upon entry.

At 12:20 PM LPA Haley began the tour of the facility with staff. There were two clients present for the visit. All client bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp and storage space. Both client bathrooms were clean and organized. Hot water temperature was measured at 105 degrees Fahrenheit in client bathroom #1 and 110.3 degrees Fahrenheit in client bathroom #2. LPA Haley observed plenty of extra linen in the closet near bathroom #2.

In the living room LPA Haley observed a locked file cabinet near the computer station with client and staff files. LPA Haley observed a COVID screening station near the front door with hand sanitizer, surgical mask, and a temperature thermometer mounted on the wall next to the front door. LPA Haley observed a washing machine and dryer with locked cabinets right above the washer and dryer used to store detergent.

The kitchen was clean and organized. All knives and sharp objects were locked in a cabinet. All burners on the stove were operational. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items. LPA observed emergency bags with food items stored in a cabinet in the kitchen. All medication was locked in a kitchen cabinet along with a couple first aid kits with all required elements.

The garage is kept locked at all times and was clean and well organized. The walkways were clear and free of clutter and tripping hazards. All hazardous chemical were neatly organized on shelves in the garage.Plenty of extra PPE was observed neatly organized on shelves in the garage. LPA Haley observed a cabinet with files of former staff and clients. An additional refrigerator and freezer with a supply of perishable food items was observed. A supply of non-perishable food items was observed neatly organized in a cabinet, and a emergency water supply was present.

Continued on LIC809C Dated 10/2/22

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: JUSTIN HOME CARE	FACILITY NUMBER: 306005238
	VISIT DATE: 10/04/2022

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The backyard was clean, organized, and free of clutter. Side exit gates were self closing and self latching. LPA observed a locked storage shed that's used for storing miscellaneous items. LPA Haley observed two shaded areas equipped with tables and chairs.

There were no bodies of water observed. Smoke and carbon monoxide detectors were tested and are operational. No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report was provided.

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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