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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005500
Report Date: 05/26/2021
Date Signed: 06/04/2021 10:21:57 AM

Document Has Been Signed on 06/04/2021 10:21 AM - 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 JULIET 1FACILITY NUMBER:
306005500
ADMINISTRATOR:DEL ROSARIO, LESTERFACILITY TYPE:
740
ADDRESS:479 S WELLINGTON RDTELEPHONE:
(209) 914-1153
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: 6DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Julieta Cervania and Lester Del RosarioTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Julieta Cervania and explained the reason for the visit. Administrator Lester Del Rosario arrived during the visit.

At 11:10 AM, LPA toured the facility with Caregiver Julieta Cervania . Facility has 6 residents in care during today's visit. LPA observed and spoke with residents in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Two rooms are single occupancy and two rooms are currently double occupancy. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet. Facility takes resident temperatures daily and LPA observed temperature documentation. Facility has covid precaution postings as well as all required department postings. Facility submitted mitigation plan to the department. LPA observed the emergency disaster plan posted in facility. LPA observed emergency food and water as well as the first aid kit. LPA toured the outside grounds and observed the shaded outside visitation area. LPA observed the exit gate is padlocked. LPA observed the locked medication storage area. Facility has surgical masks, gloves, N95 masks as well as cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19.
During the visit, LPA consulted with Licensee regarding the importance of maintaining a thirty day supply of all PPE as well as ensuring toxins are secured at all times..

Based on the observations made during the visit on 03/29/18, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2021
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 06/04/2021 10:21 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 05/26/2021 at 11:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CARE JULIET 1
FACILITY NUMBER: 306005500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed the exit gate is secured with a padlock thus posing a safety risk in an emergency. This poses an immediate health and safety risk to persons in care. (Photos).
POC Due Date: 05/27/2021
Plan of Correction
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Facility staff removed lock during visit. Cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021


LIC809 (FAS) - (06/04)
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