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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005518
Report Date: 10/26/2021
Date Signed: 10/26/2021 12:08:52 PM

Document Has Been Signed on 10/26/2021 12:08 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:JANEEN HOMEFACILITY NUMBER:
306005518
ADMINISTRATOR:JESSICA GARCIAFACILITY TYPE:
734
ADDRESS:1438 W JANEEN WAYTELEPHONE:
(657) 254-0274
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 5CENSUS: 3DATE:
10/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator Jessica Garcia TIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to conduct a case management for an incident. LPA was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedures. Administrator (AD) Jessica Garcia arrived in the facility shortly after. LPA stated the purpose of this visit.

On October 25, 2021, The Community Care Licensing Division (CCLD) Orange Regional Office received a report from this facility indicating that about 2:09 AM of the same day, Facility received a report that , Client 1 (C1) passed away while admitted in the hospital. Client 1 had been in a hospital set up since October 4, 2021.

For this visit, LPA Marin conducted a tour in the interior of the facility and observed three clients in care and five staff members on the floor. LPA conducted interviews and reviewed records that included but not limited to admission agreement, physician's report, needs and services plans, incident reports, observation logs, and hospital records.

For this visit no citation was issued at this time.

LPA Marin conducted an exit interview with AD J. Garcia; and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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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