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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005501
Report Date:
03/19/2024
Date Signed:
03/19/2024 02:03:16 PM
Document Has Been Signed on
03/19/2024 02:03 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:
JEWEL HOMECARE 1
FACILITY NUMBER:
306005501
ADMINISTRATOR:
PAO, WESLEY
FACILITY TYPE:
740
ADDRESS:
5111 HAMER LN
TELEPHONE:
(424) 270-4452
CITY:
PLACENTIA
STATE:
CA
ZIP CODE:
92870
CAPACITY:
6
CENSUS:
6
DATE:
03/19/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Nemecio Masone
Wesley Pao
TIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Nemecio Masone and explained the purpose of the inspection.
During the inspection, LPA and Staff Masone conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:
This is a one-story home with four resident bedrooms, one staff bedroom, three bathrooms, and attached two-car garage. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The backyard has a shaded sitting area. LPA observed residents watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 125.7-127.9 F degrees; a Deficiency was cited on today’s date.
LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag dated March 5, 2024. Electric stove, microwave, washer, and dryer were all inspected and observed to be operable. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked, however, various prescription medications were observed unattended on the kitchen counter, and in an unlocked kitchen cabinet and drawer; a Deficiency was cited on today's date.
(Cont. LIC809-C)
SUPERVISOR'S NAME:
Armando J Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Claudia Gutierrez
TELEPHONE:
714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
9
Document Has Been Signed on
03/19/2024 02:03 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:
JEWEL HOMECARE 1
FACILITY NUMBER:
306005501
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, AD interview, and record review, the licensee did not comply with the section cited above in four out of four client records, as they do not contain a centrally stored medication record, which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date:
03/20/2024
Plan of Correction
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AD stated they will maintain a record of centrally stored medication and keep it up to date. AD stated staff training will conducted to ensure records are accurately maintained. LPA will made an additional visit to ensure POC has been met.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above as various prescription medications were observed on the kitchen counter, in an unlocked kitchen drawer and in an unlocked kitchen cabinet, which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date:
03/20/2024
Plan of Correction
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AD stated all medication will be centrally stored and mainitained in a locked cabinet. Medication management training will be provided to staff. LPA will make an additional visit to ensure POC has been met.
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:
Armando J Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Claudia Gutierrez
TELEPHONE:
714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
2
of
9
Document Has Been Signed on
03/19/2024 02:03 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:
JEWEL HOMECARE 1
FACILITY NUMBER:
306005501
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.
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 in two out of two bathroms taps which poses a potential safety risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
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AD stated in lieu of warning signs, water temperature will be adjusted to be between 105 and 120. AD stated water temperature will be monitored on an ongoing basis to ensure temperature is maintained below 125. LPA will make an additional visit to ensure POC has been met.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, AD interview, and record review, the licensee did not comply with the section cited above as staff records indicate staff has not had training in the past two years, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
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AD stated staff training will be conducted immediately to meet regulation requirement. AD will provide LPA with proof of staff training conducted via email by POC date.
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:
Armando J Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Claudia Gutierrez
TELEPHONE:
714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
3
of
9
Document Has Been Signed on
03/19/2024 02:03 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:
JEWEL HOMECARE 1
FACILITY NUMBER:
306005501
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, AD interview, and record review, the licensee did not comply with the section cited above as AD was unable to provide any documentation of staff training conducted, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
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AD stated staff training will be conducted immediately to meet regulation requirement. AD will provide LPA with proof of staff training conducted via email by POC date.
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, AD interview, and record review, the licensee did not comply with the section cited above as AD was unable to provide any documenation of initial staff training conducted, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
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AD stated intial staff training was conducted and has been completed and stated documentation will be provided to LPA via email by POC date.
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:
Armando J Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Claudia Gutierrez
TELEPHONE:
714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
4
of
9
Document Has Been Signed on
03/19/2024 02:03 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:
JEWEL HOMECARE 1
FACILITY NUMBER:
306005501
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above as six out of six resident rountine medications are pre-poured into a weekly medication organizer a week in advanced, which poses a potential health and safety risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
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AD stated medication will no longer be prepared a week in advance and weekly medication organizer will no longer be used, medication will be maintained in its originally received container and medication management training will be conducted. AD will provide LPA with proof of staff training conducted via email by POC date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in two out of two resident files which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
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AD stated they will update all appraisals as needed and as frequently as necessary. AD will provide LPA with a copy of re-appraisals for residents via email by POC date.
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:
Armando J Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Claudia Gutierrez
TELEPHONE:
714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
5
of
9
Document Has Been Signed on
03/19/2024 02:03 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:
JEWEL HOMECARE 1
FACILITY NUMBER:
306005501
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, AD interview, record review, the licensee did not comply with the section cited above in two out of two resident records, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
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2
3
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AD stated they will arrange a meeting when there is a significant change in residents' condition, or once every 12 months, whichever occurs first, AD will provide LPA with proof of POC via email by POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on AD interview and record review, the licensee did not comply with the section cited above as disaster drills are not being documented which poses a potential health and safety risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
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2
3
4
AD stated a record will be maintained of disaster drills conducted and will provide LPA with a copy via email by POC date.
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:
Armando J Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Claudia Gutierrez
TELEPHONE:
714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
6
of
9
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:
JEWEL HOMECARE 1
FACILITY NUMBER:
306005501
VISIT DATE:
03/19/2024
NARRATIVE
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House Manager Rowel Rivera arrived at 10:30 a.m. and Administrator (AD) Wesley Pao arrived at 11:00 a.m. to assist with the inspection. LPA reviewed four resident files and three staff files. Two out of four resident files did not have an appraisal dated in the last twelve months; a Deficiency was cited on today’s date. Staff files did not contain any documentation for initial staff training or staff training conducted in the past year and AD was unable to provide LPA with a copy of staff training conducted; a Deficiency was cited on today’s date. LPA interviewed four residents and two staff.
Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISOR'S NAME:
Armando J Lucero
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR NAME:
Claudia Gutierrez
TELEPHONE:
714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
9
of
9