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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005502
Report Date: 05/10/2022
Date Signed: 05/10/2022 04:04:57 PM


Document Has Been Signed on 05/10/2022 04:04 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 2FACILITY NUMBER:
306005502
ADMINISTRATOR:PAO, WESLEYFACILITY TYPE:
740
ADDRESS:20152 RIVERSIDE DRTELEPHONE:
(424) 270-4452
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY:6CENSUS: 4DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jehla GabrielTIME COMPLETED:
03:35 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 and explained the reason for the visit. Licensee Jehla Gabriel arrived during the visit. Jehla Gabriel has an administrator certificate expiring on 08/12/2023.
At 1:35 PM, LPA toured the facility with Caregiver Dondie Puyeo. Licensee joined the tour in progress. Facility has 4 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 resident's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Three rooms are single occupancy and one room is 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 and staff temperatures daily. Facility has covid precaution postings as well as required department postings. LPA observed the emergency disaster plan posted in facility. LPA observed adequate emergency food and water as well as the first aid kit. LPA observed ample food supply in kitchen. At 2:00 PM, LPA observed unsecured Tylenol and eye drops in an unlocked kitchen cabinet. LPA toured the outside grounds and observed the shaded outside visitation area. Exit gate is unlocked and self latching. Garage door is unlocked and LPA observed unsecured paint, Windex, and lighter fluid. LPA observed a free standing back house in the yard occupied by a tenant. The front door of the back house is unlocked and LPA observed unsecured medication. LPA verified tenant is criminally cleared and associated to facility. LPA observed the locked medication storage area. Facility has ample supply of surgical masks, N95 masks and gloves 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. LPA reviewed four resident files and all files have updated emergency information.
Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with Administrator and a copy was provided as well as appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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 05/10/2022 04:04 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 2
FACILITY NUMBER: 306005502

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
The following shall be stored inaccessible to residents with dementia
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 unsecured noted items in LIC 809. Resident 2 is diagnosed with Dementia. This poses an immediate health and safety risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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Licensee to secure noted items and forward proof to LPA by POC due date.
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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
LIC809 (FAS) - (06/04)
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