306005418-12-16-2024-22-AS-JTIE-DBZST8-20241216130907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005418
Report Date: 12/16/2024
Date Signed: 12/16/2024 01:10:03 PM

Document Has Been Signed on 12/16/2024 01:10 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	JC HOME FOR SENIORS - LOVE		FACILITY NUMBER:	306005418
ADMINISTRATOR/ DIRECTOR:	PARUNGAO, MARIA- EMETERIO		FACILITY TYPE:	740
ADDRESS:	19851 ISTHMUS LANE		TELEPHONE:	(714) 968-9795
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92646
CAPACITY: 5	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	12/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:00 AM
MET WITH:	Administrator, Cherry Parungao		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE

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On December 16, 2024, Licensing Program Analyst (LPA's) Jenifer Tirre and Eboni Bentley conducted an unannounced required visit using the CARE Inspection Tool. LPA's were greeted by staff and granted entry after stating the purpose of the visit. Administrator (Admin) Cherry Parungao was present to assist with the facility inspection on today's date.

The facility is licensed for five (5) non-ambulatory residents, (1) bedridden with approved hospice waiver for three (3) residents.

This is a single story with a two-car garage facility. The facility has five bedrooms (four resident bedrooms and one staff bedroom) and two bathrooms.

At around 10:00 AM, LPA's conducted a tour of the physical plant accompanied by Administrator Cherry Parungao, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 112.4 degrees F. A comfortable temperature of 70 degrees F. was maintained in the facility.

LPA's observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and cleaning suplies were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has one fire extinguisher,which was mounted and was charged. A review of the Medication Records Administration (MAR) was conducted, and LPA's observed the records are in compliance.

CONTINUED ON 809C

Lourdes Montoya	TELEPHONE: (714) 703-2870
Jenifer Tirre	TELEPHONE: (714) 401-6844
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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 12/16/2024 01:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JC HOME FOR SENIORS - LOVE	FACILITY NUMBER: 306005418
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in two out of four stove burners were non operational which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2024
	Plan of Correction
1 2 3 4	Licensee to fix stove top burners and provide proof by POC due date 12/30/24.

Section Cited

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to Facility had several food items such as oatmeal, turkey bacon and ground beef that were past expiration date which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2024
	Plan of Correction
1 2 3 4	During visit Facility corrected deficiency by throwing away food items. Licensee to check monthly food supplies and provide a in service training regarding food service requirements. Licensee to provide proof of POC due date by 12/30/24

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lourdes Montoya	TELEPHONE: (714) 703-2870
Jenifer Tirre	TELEPHONE: (714) 401-6844
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JC HOME FOR SENIORS - LOVE	FACILITY NUMBER: 306005418
	VISIT DATE: 12/16/2024

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During the visit, LPA's observed the facility's infection control practices. LPA's observed screening protocols for visitors, staff, and residents. LPA's observed the facility has a supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working land line phone was operational. The last fire drill was conducted on September 10, 2024. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective September 19, 2024 - September 19, 2025.

A review of four residents (R1-R4) service files and three staff (S1-S3) personnel files revealed to be complete. The facility has current administrator listed as Maria Parungao and certification is listed as pending renewal for August 12, 2024. Facility has supply of emergency food and water.

Based on the observations made during today's visit, the following deficiencies are being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Maria Cherry Parungao.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

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