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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005439
Report Date: 08/08/2022
Date Signed: 08/08/2022 03:17:12 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/08/2022 03:17 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:CARE JORDAN SENIOR HOMESFACILITY NUMBER:
306005439
ADMINISTRATOR:GIDEON LIMPIADOFACILITY TYPE:
740
ADDRESS:8728 CANARY AVENUETELEPHONE:
(562) 365-4155
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
08/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:42 PM
MET WITH:Sara DeLaCruz, House ManagerTIME COMPLETED:
03:30 PM
NARRATIVE
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required/ annual Inspection visit. LPA Quiroz was greeted and granted entry into the facility by House Manager (HM) HM Sara Dela Cruz and explained the reason for the visit. During visit, LPA Quiroz called and spoke to Assistant Administrator Carmien Calangie who indicated Sara Dela Cruz would be the one present during today's inspection visit due to Administrator and Assistant Administrator not being able to be present during today's visit. This facility is licensed to provide services to residents age 60 and over, 6 Non Ambulatory Residents, of which 1 may be Bedridden and has a hospice waiver for three residents. Facility is currently providing services to one (1) resident. Administrator Gideon (AD) Limpiado has an active Administrator Certificate with expiration date of 4/22/2022. AD Gideon Limpiado indicated waiting for new certificate, and agreed to submit to CCL upon receiving it.

At 2:12pm, LPA Quiroz toured the facility with (HM) Dela Cruz . The Facility has currently 5 residents in care during today's visit. LPA Quiroz observed one resident in living-room supervised by caregiver. During today's toured, LPA Quiroz observed four of five residents in their bedrooms laying down, appeared to be sweating. 4 of 5 residents indicated "Too hot. Way too hot." Facility indoor temperature throughout the facility was recorded to be between 88-89 degrees. Resident 4 and Resident 5 indicated "We have been asking for air conditioner, too hot." This was verified with house Manager Sarah Delacruz. (SEE LIC 809-D)
All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer as well as hand washing. Facility has 4 single occupancy bedrooms, 1 shared bedroom for 2 occupants, 2 caregiver bedrooms and 2 bathrooms for staff, visitors and residents.


CONTINUED ON NEXT PAGE...
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
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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Document Has Been Signed on 08/08/2022 03:17 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CARE JORDAN SENIOR HOMES
FACILITY NUMBER: 306005439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited

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80088:Furniture, Fixtures, Equipment, and Supplies .(a)A comfortable temperature for clients shall be maintained at all areas.(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F... and a maximum of 85 degrees F...CONTINUED BELOW
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At 2:12pm, LPA Quiroz alond with HM Sara Delacruz toured the facility. LPA Quiroz observed four of five residents in their bedrooms laying down, appeared to be sweating. 4 of 5 residents indicated "Too hot. Way too hot." Facility indoor temperature throughout the facility was recorded to be between 88-89 degrees. CONTINUED...
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Resident 4 and Resident 5 indicated "We have been asking for air conditioner, too hot." This was verified with house Manager Sarah Delacruz.

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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
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: CARE JORDAN SENIOR HOMES
FACILITY NUMBER: 306005439
VISIT DATE: 08/08/2022
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The Facility indicated screening all visitors to the facility, and indicated recording resident's temperatures daily. LPA Quiroz observed the screening/ sanitizing station in the facility upon entrance. The Facility utilizes a visitor sign in sheet. Facility takes resident temperatures daily and documents results. LPA Quiroz observed ample sanitizer spread out throughout the facility. Facility has COVID-19 precaution postings at facility entrance and throughout the facility. Facility mitigation plan has been submitted and approved during today's visit. LPA Quiroz toured the outside grounds and observed the shaded outside visitation area. Exit gates are unlocked. LPA Quiroz observed the locked medication storage area. Facility has a plan for COVID-19 testing residents and staff as needed as well as a plan for isolation and quarantine. Four of five residents and staff are vaccinated for COVID-19 and one booster.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC809 (FAS) - (06/04)
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