306005477-11-13-2024-22-AS-JTIE-DAZ2YC-20241113164831

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005477
Report Date: 11/13/2024
Date Signed: 11/13/2024 04:48:50 PM

Document Has Been Signed on 11/13/2024 04:48 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-CARE		FACILITY NUMBER:	306005477
ADMINISTRATOR/ DIRECTOR:	PARUNGAO, MARIA E		FACILITY TYPE:	740
ADDRESS:	15332 SHASTA LANE		TELEPHONE:	(714) 622-5118
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Administrator, Cherry Parungao		TIME VISIT/ INSPECTION COMPLETED:	04:50 PM

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On 11/13/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Administrator (Admin) Cherry Parungao and Jay Parungao were present to assist with the facility inspection on today's date.

The facility is licensed for six (6) non-ambulatory residents, 1 Bedridden with approved hospice waiver for two (2) residents. Currently, there are two (2) Hospice residents present during today’s visit.

This is a single story with a two-car garage facility. The facility has six bedrooms (four private rooms, one shared room and one staff room), and three bathrooms.

At around 12:52PM, LPA conducted a tour of the physical plant accompanied by Administrator, and the following was observed: 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 118.0 degrees F. A comfortable temperature of 74 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has supply of emergency food and water. A fire extinguisher was charged, facility has one fire extinguisher. A review of the Medication files was conducted.

CONTINUE ON 809C

Lourdes Montoya	TELEPHONE: (714) 703-2870
Jenifer Tirre	TELEPHONE: (714) 401-6844
	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

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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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-CARE	FACILITY NUMBER: 306005477
	VISIT DATE: 11/13/2024

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA 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 landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 9/19/2024 - 9/19/2025. The facility is current on Community Care Licensing annual dues.

A review of four residents (R1-R4) service files and two staff (S1-S2) personnel files revealed to be complete. The facility has the current administrator's certification on file for Jay Parungao # 7000219740 - Expiration 11/10/25.

No deficiencies during this inspection visit.

An exit interview was conducted with Administrator, and a copy of the report was provided.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC809 (FAS) - (06/04)

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